Consent to Treat : Cortez Adventist Christian School Cortez CO

Only designated staff will have access to the completed form. This form must be filled out at the beginning of each school year to cover the activities for the school year. A copy of each student's form must be taken on off-campus activities.

Date

Student's full name

Age

Date of Birth

Social Security Number

Parent/Guardian Information

Father/Guardian Name

Work Number

Home Number

Cell Number

Social Security Number

Mother/Guardian Name

Work Number

Home Number

Cell Number

Social Security Number

Section

Please describe allergies to substances and medications

If on regular medication, please specify

Date of Last Tetanus Shot

Please give the name of your local family physician to be called in case your child becomes ill or has an accident at school and you cannot be reached

Physician's Office Address

Physician's Office Number

Please give the name of a relative or friend who has consented to assume the responsibility of your child in case of illness or accident until you can be reached. In case of any changes in the named person, notify the school in writing.

Number of Realtive/Friend

Address of Realtive/Friend

The above named student is/is not covered by health insurance

Present Health Insurance Company

Policy Number

If emergency service involving medical action or treatment is required and neither the parent nor the family physician can be reached for consent, the parents hereby consent to the rendering of such emergency medical service for the above named student as shall be necessary in the medical opinion of the doctor rendering service.

Date

Cortez Adventist Christian School

Quality Christian Education

Consent to Treat

Parent/Guardian Information

Section

Related Information