Consent for Emergency Treatment 2017-18 School Year

This form is information that goes with your child in case of emergency medical treatment or transport to the hospital.

Name of Child*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Name of Parent/Guardian*
First Last
Emergency Phone Number
Name of Parent/Guardian
First Last
Emergency Phone Number
Emergency contact other than parents*
First Last
Emergency
Emergency Contacts Phone Number*
Child’s Physician
Prefix First Last
Physician's Phone
Physician's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Last Physical or Doctor’s Visit (must be within 2 years)
Date Format: MM slash DD slash YYYY
Child’s Dentist
Prefix First Last
Dentist's Phone
Dentist's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Child's last Dentist Visit. Please write "none" if your child has not seen a dentist prior to enrolling*
List Child’s Allergies and Medical Conditions. If your child has no allergies you must write none.*
If your child's allergies require an EPI pen @ school; your child’s healthcare provider must complete and sign a Report of Food Allergy. If your child has severe Asthma that requires an inhaler at school; your child’s healthcare provider must complete a Child's Asthma Plan as applicable. The school does not serve any nut products for snacks. Parents may provide their child’s snacks when food allergies exist.
Has your child ever had a seizure or a fainting spell?*
- Yes
- No
What was the cause and at when?*
I hereby give permission for my child to be given emergency treatment by a qualified staff member of Bellevue Montessori School. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.*
- In the event that I cannot be contacted, I further consent to the medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, hospital, or 911 emergency personnel when deemed immediately necessary or advisable by a physician to safeguard my child’s health.
Signature*
Date
Date Format: MM slash DD slash YYYY
Test
- Yes
- No

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18	19	20	21	22	23	24
25	26	27	28	29	30
S	M	T	W	T	F	S

S	M	T	W	T	F	S
				1	2	3
4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30

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Consent for Emergency Treatment 2017-18 School Year

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