NOTARIZED EMERGENCY FORM

NOTARIZED EMERGENCY FORM
Student’s Name: ___________________________________________________________________________________
Address: ___________________________________________________________________________________________
Age: _________ Date of Birth: _______________ Sex: ________Phone: _ ___________________________________
Father’s Name: ________________________________________ Work Phone: _______________________________
Mother’s Name: ________________________________________Work Phone: _______________________________
E-Mail Address: ____________________________________________________________________________________
Person’s who may be contacted in case of an emergency if for some reason the parent or guardian
cannot be reached (and authorized to remove child from center).
___________________________________________________________________________________________________
Name
Address
Phone
Relationship
___________________________________________________________________________________________________
Name
Address
Phone
Relationship
Allergies (Food, Medication, etc.)
_________________________________________________________________
Special Medical Needs: ____________________________________________________________________________
Hospital Preference: _______________________________________________________________________________
Child’s Physician: ___________________________________________________Phone: ________________________
We authorize an employee of Dayspring’s ACT II Program, in whose care the minor has been entrusted,
to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, or
hospital care, to render to the minor under the general supervision, and on the advice of any physician
at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in
connection with such medical and/or dental services rendered to the aforementioned child pursuant to
this authorization. Should it be necessary for our (my) child to return home due to medical reasons or
otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give
permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has
been entrusted while attending and participating in activities sponsored by Dayspring’s ACT II Program.
Permission is hereby granted to meet the medical needs of our (my) child in case of any emergency.
________________________________________________________
Signature of Parent/Guardian
Date
_____________________________________
The Foregoing instrument was acknowledged before me the undersigned authority on this _____ day of
_________________, 20___ by ______________________________________
who has provided current identification, and who did take an oath or is personally known.
______________________________________________
Signature of Notary Public-State of Florida
____________________________________
Expiration