Student Emergency Medical Care Authorization Form

The Colorado Department of Human Services requires that DCP maintain a dated written authorization for emergency medical care for each child enrolled at the school.

• I give my permission for DCP to call for emergency medical care for my child.
• I understand that in an emergency situation, every effort will be made to notify me immediately (or the persons whom I have authorized to assume responsibility for my child in an emergency situation, in the event that I cannot be reached) after appropriate emergency personnel have been called.
• I understand that the emergency personnel will determine where to transport my child in the event of an emergency.
• I authorize DCP to transfer my child's health record to the hospital and/or medical personnel that care for my child in the event of an emergency.
• I understand that DCP does not have medical personnel on site to assist my child in the event of a medical emergency.
• I authorize DCP staff to administer first aid that is within their training and acceptable by the Colorado Department of Human Services.
• I further agree to assume all financial responsibility for all expenses incurred in the transportation and treatment of my child in the event of an emergency.

PLEASE NOTE

If you have more than one child enrolled at DCP you will need to fill out a separate form for each student!