Emergency Contact/Consent For Emergency Treatment
Date of Birth
1 Parent's / Legal Guardian's Name
2 Parent's/ Legal Guardian's Name
List at least one other person who can either pick up and/or assume responsibility for your child in the event of an emergency if parents cannot be reached. One non-guardian contact person must be listed with their phone number:
Relationship to Client
Is there anyone NOT authorized to pick up or drop off your child?
Does your child have any health concerns (medications, chronic conditions, behavioral or mental disabilities) that we should know about in order to facilitate safe and successful participation?
If Yes, please describe:
Please list all allergies (and reactions) including food, medications, etc.:
Medications and frequency of use:
Physician's Phone Number:
Is there additional information we should know which would help us in working with your child?
I, the undersigned, hereby give permission to the Kate McClain Social Skills staff to secure emergency medical and/or surgical treatment for my child while in their care. I understand that every effort will be made to contact the parent/ legal guardian/ emergency contact in the event of an emergency requiring medical attention unless a life-threatening situation is at hand or circumstances do not allow. In the event the parent/ legal guardian/ emergency contact cannot be reached, I authorize the staff at Kate McClain Social Skills to transport (or arrange medical transport - i.e. ambulance) for the child to the nearest medical care facility. I also hereby authorize the performance of medical, surgical, or diagnostic procedures, including the administration of anesthesia, and injections of medications for the child named as deemed necessary or advisable by the attending physician or surgeon in the diagnosis of emergency treatment for the child named in the event that parent/ legal guardian/ emergency contact cannot be reached for direct authorization of treatment. All expenses of such care will be accepted by the parent/ legal guardian/ emergency contact, including fees for an ambulance, if deemed necessary by staff.
Signature of Parent/Legal Guardian
Do Not Fill This Out