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Connecticut ther: _________________________ Rules and Habits pecial Conditions: After Hours Number: Schedule & Instructions Meals: __________________________ Snacks: _________________________ Naps: __________________________ Bedtime: _______________________ O Medical/Health/Insurance Care Information Child's Doctor Name: Address: Office Telephone: Health Insurance Company: Group or Policy Number: Telephone Number: Medications: Allergies: Immunizations: S's Age: Parent(s) and Other Contacts Mother's Name: Father's Name: Address of Parent(s): Home# Second Contact Name: Relationship: Third Contact Name: Relationship: Work# Phone Number: Phone Number:______ (state). ________________________________ Signature of Parent ________________________________ Signature of Parent Child Care Information and Instructions Child's Name: Child's Nickname: Childfor the Child. This Consent Form may be revoked at any time before the expiration date with written notice to Organizer. Signed on ________________ (date), at _______________________ (city), _________(s) before administering or authorizing any treatment. Notwithstanding other provisions in this Consent Form, Organizer shall not have the authority to withhold or withdraw life-sustaining procedures X-ray examination, performance of operations, diagnostic and other procedures. If there is no medical emergency, the guardian will first use reasonable efforts to contact the parent(s) and/or guardiandical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child. Health care shall include but not be limited to the administration of anesthesia, ians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent form required by mestaff, employees, agents and representatives of Organizer to provide for, approve and authorize any health care at any hospital, emergency room, doctor's office or other institution; employ any physic_ (Name of "Organizer") and to the participation of the Child in all events relating to the activity on _______________ through _______________. The undersigned hereby further authorize(s) any of the (the "Child"), hereby consents to the participation by the Child in ____________________________________________________ (describe activity) conducted by _____________________________________________cial Security Number: ____________________________________ Address: ________________________________________________ The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above childgal advice. Furthermore, this information is general information that is not state specific. PARENTAL PERMISSION AND MEDICAL CONSENT RE: Name: _________________________________ born on __________ So beginning and an "end/expiration" date, the Parent(s) can revoke the document at any time even before the end date. Please note that this information is not intended as and is not a substitute for ley medical procedures. Medical personnel will also generally feel more comfortable dealing with someone who can provide this type of document. Although the Parental Permission and Medical Consent has antal or any other type of care. This can be especially important on a school or scouting trip if a medical emergency arises when the parents may not be readily available to consent to certain emergenct available, the organizers of the activity will be able to better deal with any types of emergency involving the children and can avoid potential problems when, for example, arranging for medical, detivity, which is defined in the form. The consent form also grants the organizers of the activity the power to make health care related decisions on behalf of the child. By having this type of documenity (i.e. a school trip, excursion, scouting trip, sports team etc...). A "Parental Permission and Medical Consent" Form allows parents to give consent for their child to participate in a specified acdlegalforms.com Information Parental Permission and Medical Consent It sometimes is necessary for parents to give their permission so that their child can participate in some form of organized activ only be a starting point for you and should not be used without consulting with an attorney first. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at fines of the Parental Permission and Medical Consent and Child Care Instructions document for their records. [_] These forms are not intended and are not a substitute for legal advice. These forms shouldinal Parental Permission and Medical Consent and Child Care Instructions document should be given to the organizers of the activity the child will be participating in. [_] The Parents should keep copicklist; and (4) additional useful information about Parental Permission and Medical Consent documents. [_] Either one or both Parents can sign the Parental Permission and Medical Consent. [_] The origInstructions & Checklist Parental Permission and Medical Consent [_]This package contains a (1) Parental Permission and Medical Consent; (2) Child Care Instructions (3) simple instructions plus a che Connecticut