Beaufort Jasper EOC Head Start

Emergency Medical Treatment

Child's Last Name:*

Child's Middle Name:

Child's First Name:*

Date of Birth:*

Parent's First Name:*

Parent's Middle Name:

Parent's Last Name:*

What program option are you registering for?*

Center:*

I, , hereby give my consent for emergency medical/dental treatment of the child listed below by any licensed physician or dentist while under the care of Beaufort-Jasper EOC Head Start and for transportation of the child to and from the source of emergency treatment.

This care may include examinations and any test which, in the opinion of the physician, are deemed necessary or advisable.

This does not include the right to perform surgical operations without further consent, except in the case of an emergency after an effort has been made to contact me, and I am not available.

THIS FORM MUST BE UPDATED YEARLY AND IS ONLY VALID FOR THE CURRENT SCHOOL YEAR.

I confirm that I have read and understand this form. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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