Office Use: Crib Mon. ____ Wed. ____ Both: _____ Toddler MWF ____ T/Th ____ Young 2’s MWF ____ T/Th ____ Middle 2’s MWF ____ T/Th ____ Older 2’s MWF ____ T/Th ____ Younger 3’s MWF ____ T/Th ____ *Middle 3’s MWF ____ T/Th ____ *Older 3’s MWF ____ T/Th ____ *Young 4’s MWF ____ T/Th ____ Pre K 4’s MWF ____ T/Th ____ *Children must be potty trained to enter these classes.
*AUTHORIZATION FOR EMERGENCY CARE TO MINOR
I/We the undersigned, parent(s) or legal guardian of the minor listed below:
do hereby authorize any X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of:
(Name of adult person who is temporary custodian of minor)
The temporary custodian of the minor: whether such diagnosis or treatment is rendered at the office of the physician or dentist, or at the hospital licensed by the State of Oklahoma. I/We authorize the physician or dentist to call in any necessary consultants, in his/their discretion. We further authorize said physician or dentist to exercise his/their discretion in authorizing the disposal of severed tissues or member.
It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment. I/We authorize Asbury Weekday Preschool to transport the above-named minor to any medical facility and/or call my family physician.
This consent shall remain effective until 6:00 pm on the 31st day of May 2021, unless sooner revoked in writing, delivered to said physician or dentist or said persons entrusted with the custody, care and control of said minor child or children.
I/We understand and give consent for Asbury UMC to take and/or use photographs, voice, video or digital tapes of myself and/or my child(ren) for advertising or public display.