CONSENT FOR EMERGENCY MEDICAL TREATMENT

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 Cornejo Family Child Care/Tiny Sprouts Classroom TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D OSTEOPATH (D.O OR DENTIST (D.D.S FOR Your Child's Name. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES
DATE

MonthDayYear
Date
Your Email Address
example@example.com
Signature
HOME ADDRESS
HOME PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
LIC 627 (9/08) (CONFIDENTIAL)
Should be Empty: