In case of an emergency or a serious illness and the parents cannot be reached immediately, I hereby authorize the provider to obtain emergency medical care and/or provide emergency medical transportation for my child.
Name of ParentͬGuardian Date
This form must be reviewed annually by the parent/guardian, and any changes noted.
This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.
There must be a separate health assessment form for each sibling.
This form must be completed for each individual child enrolled, and must be reviewed annually by the parent/guardian, and any