STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
________________________________________
TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________
THIS CARE MAY BE GIVEN UNDER
NAME
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.
DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
HOME ADDRESS
HOME PHONE
LIC 627 (9/08) (CONFIDENTIAL)
WORK PHONE
