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Medical Treatment Authorization 061311

The document authorizes Children's Academy to provide emergency medical treatment for the child in case of illness or injury. It lists the child's physician and dentist contact information. The parent accepts responsibility for medical payment. The parent initials boxes giving permission for activities, sunscreen use, developmental screening, and photo posting with no identification. The parent acknowledges reading and understanding the enrollment terms.

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nicoletagr2744
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59 views1 page

Medical Treatment Authorization 061311

The document authorizes Children's Academy to provide emergency medical treatment for the child in case of illness or injury. It lists the child's physician and dentist contact information. The parent accepts responsibility for medical payment. The parent initials boxes giving permission for activities, sunscreen use, developmental screening, and photo posting with no identification. The parent acknowledges reading and understanding the enrollment terms.

Uploaded by

nicoletagr2744
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Authorization for Emergency Medical Treatment and Releases

If my child, _________________________________, should become ill or injured at Children's Academy,


(Child's full name)
I understand that the facility will (1) contact me immediately and (2) contact the person(s) I have designated if I cannot be reached.

Should the facility be unable to reach me and/or the person(s) designated, they are authorized to arrange for
immediate emergency treatment. The medical facility is authorized to administer emergency medical treatment necessary to en-
sure the health and safety of my child.

Physician’s Name _____________________________________ Physician’s Phone

Dentist’s Name ______________________________________ Dentist’s Phone

I will accept responsibility for payment of medical services.

Signature ____________________________________________

Relationship ___________________________________________

Date _____________________________________________

Please Initial:

_____I understand and agree that Children's Academy will provide the nutritional needs of my child for lunch and snacks.

_____I give permission for my child to participate in any and all activities (i.e. field trips). I release Children's Academy Inc.
and/or staff of any liability while on the above mentioned activities or trips. I understand that my child is covered by an accident
insurance policy while participating in school activities.

______I authorize Children’s Academy to apply sunscreen during Summer Camp.

______I understand and agree that Children’s Academy will utilize the Ages and Stages Questionnaire (ASQ) to assess my
child’s development. The information obtained will be shared with me and used to plan academic support as needed.

______I understand and agree that Children’s Academy may photograph my child and post the photo on a secure site. I
understand that no identifying information will be used.

______I have read the Children’s Academy Family Handbook (found at www.childrensacademybrandon.com/enrollment),
as well as this enrollment form. I have been given the opportunity to ask questions and I understand the terms of enrollment
as stated.

______I will be responsible for payment of all fees due to Children’s Academy and all legal fees which may arise for
non-payment.

______I have received a copy of the Know Your Child Care Facility Brochure (found at
www.childrensacademybrandon.com/enrollment) in accordance with the Hillsborough County Child Care Licensing
Ordinance.

______I have received a copy of the Influenza Virus Brochure (found at www.childrensacademybrandon.com/enrollment)
created by the Department of Children and Families.

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