Authorization For Emergency Medical Treatment Form For Child(ren)’s Medical Emergency Authorization For Emergency Medical Treatment Form Your Name * Your Email * Your Phone * I hereby attest that I understand (please check) * parent/guardian of below named children, give my permission for the staff of Fremont Connections to arrange and secure Emergency Medical transportation, treatment and/or use acceptable procedures of basic first aid on myself or my child(ren) if I am absent or unable to make the arrangements myself. I fully understand that the cost of treatment will be my responsibility. Child/Children Name(s) * THIS FORM MAY BE GIVEN TO FIRST RESPONDERS IN CASE OF A MEDICAL EMERGENCY PHYSICIAN Name * PHYSICIAN Phone * DENTIST Name * DENTIST Phone * PLEASE LIST ANY HEALTH CONDITIONS, ALLERGIES, MEDICATION FOR YOU OR YOUR CHILD/CHILDREN THAT FREMONT CONNECTIONS AND/OR A MEDICAL PROVIDER SHOULD BE AWARE OF: * Your Signature * signature keyboard Clear Date Submit If you are human, leave this field blank.
