Family Information

Child Information

Emergency Care Authorization

I certify that I am a parent or legal guardian of the child or children named above and give consent for emergency medical and/or surgical treatment, and/or transportation to a care facility should my child’s condition require it in my absence. I understand that, time and conditions permitting, reasonable attempts will first be made to contact me and any designated representatives in such a case. I hereby assume all financial responsibility for such actions taken on behalf of my child.