PLEASE READ IN FULL THE FOLLOWING
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT, IF NECESSARY.
SIGNATURE AND DATE ARE REQUESTED:
We, hereby, give our full consent and permission to the Clare Woods Academy to contract the medical services of the closest hospital facility, to do everything necessary, including surgery, to save the life of our child. This consent is given in the event that we cannot be contacted in time to sign the hospital consent form.
If an emergency should arise, it is our understanding that we will immediately be contacted by telephone at the emergency numbers listed above. We will also notify Clare Woods Academy of any changes to our address and phone number contacts during the school year. I understand that by failing to do so as soon as the change occurs, may result in unnecessary time delays in notifying me of any emergency with my child.
When we are contacted, we will, in person or by telephone, contact the Hospital to reaffirm with the Hospital said authorization. We fully understand that we would assume all financial responsibilities and obligations for these medical services of the doctor and/or hospital care.
I (we) certify and attest that the information I (we) submitted and statements on this form are complete and accurate to the best of our knowledge and belief.