2021-22 Consent for Emergency Treatment Form

This form is information that goes with your child in case of emergency medical treatment or transport to the hospital.

Name of Child*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Name of Parent/Guardian*
First Last
Emergency Phone Number*
Name of Parent/Guardian*
First Last
Emergency Phone Number*
Emergency contact #1 (other than parents)*
First Last
Emergency contact #1 relationship to the child*
Emergency Contact #1 Phone Number*
Emergency Contact #1 Address*
Street Address Address Line 2 City State ZIP Code
Emergency Contact #2 Name*
First Last
Emergency Contact #2 Phone*
Emergency Contact #2 Address*
Street Address Address Line 2 City State ZIP Code
Relationship to the child*
Child’s Physician*
Prefix First Last
Physician's Phone*
Physician's Address*
Street Address Address Line 2 City State ZIP Code
Date of Last Physical or Doctor’s Visit (must be within 2 years)*
Date Format: MM slash DD slash YYYY
Child’s Dentist*
Prefix First Last
Dentist's Phone*
Dentist's Address*
Street Address Address Line 2 City State ZIP Code
Date of Child's Last Dental Appointment. Please write none if your child has not had an appointment.*
List Child’s Allergies and Medical Conditions. If your child has no allergies you must write none.*
Is your child currently on any prescribed medication?*
- Yes
- No
List each medication, frequency, dosage and reason.
If your child's allergies require an EPI pen at school; your child’s healthcare provider must complete and sign a Report of Food Allergy. If your child has severe Asthma that requires an inhaler at school; your child’s healthcare provider must complete a Child's Asthma Plan as applicable. The school does not serve any nut products for snacks. Parents may provide their child’s snacks when food allergies exist.
Has your child ever had a seizure or a fainting spell?*
- Yes
- No
What was the cause and at when?
I hereby give permission for my child to be given emergency treatment by a qualified staff member of Bellevue Montessori School. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.
- In the event that I cannot be contacted, I further consent to the medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician, hospital, or 911 emergency personnel when deemed immediately necessary or advisable by a physician to safeguard my child’s health.
Signature*
Date
Date Format: MM slash DD slash YYYY

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Bellevue Montessori School

2021-22 Consent for Emergency Treatment Form

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