Consent to Emergency Medical Treatment
Dallas County Community College District (DCCCD)
This form grants authority to the College or its employees to consent to and arrange for medical treatment for a minor
(under age 18) enrolled in a College of DCCCD in the event of an emergency, where the minor is not accompanied by a
parent or legal guardian and it may not be feasible or practical to contact a parent or legal guardian to obtain consent.
Name of Minor:
Date of Birth: Student ID#:
Home Address (Street, City, State, Zip Code):
Parent/Guardian Name: Relation to Minor:
I, , the parent/legal guardian of (minor), give my
consent for the College to authorize emergency medical treatment for the above-named minor by a licensed health care
professional, should the need arise, while he/she is enrolled in and attending a College of the DCCCD. This consent will
be in effect from this date until minor is 18 years of age, unless cancelled earlier by me in writing.
The undersigned is responsible for all medical costs associated with this authorization.
Signature of Parent/Legal Guardian Date
In the event a Parent or Legal Guardian cannot be reached, please contact:
Emergency Contact (Name, Phone):
Relation to Minor:
Emergency Contact (Name, Phone): Relation to Minor:
Medical Information Related to Minor:
Pertinent Medical History:
If necessary, please attach a separate page listing any additional allergies, medications or medical history.
OFFICE USE ONLY
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