Granny’s Garden School

2007 Emergency Consent Form

Please complete a form for each child.

In the event of an emergency, I/We hereby authorize Granny’s Garden School staff to give consent for all medical and/or surgical treatment that may be required for our child. I/We understand that every attempt will be made to first contact the parent.

Child's name:Date of Birth: __________Age: ______

Name of parent or guardian:___________________________________________________

Address: __________________________________________________________________

City, State, Zip_____________________________________________________________

Home Phone:_______________________ Cell Phone:_____________________________

Place of Work:_______________________Work Phone:___________________________

Best phone to reach you:______________Is this (circle): Home  Work   Cell 

Email Address: _________________________________________

Alternate Emergency Contacts:

Name

Relationship to child

Phone

Physician name:__________________________Phone: _______________________

Physician Address:____________________________________________________________

Current Medications:____________________________________________________________

Date of Last Tetanus Shot:________________________________________________

Chronic Illnesses:_______________________________________________________________

Allergies:_____________________________________________________________________

Other Information:______________________________________________________________

Health insurance provider:_______________________________________________________

Member number:_______________________________Group number:__________________

Signed:___________________________________________Date:______________