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Emergency Consent to Treat
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   Columbia Adventist Academy
 
Emergency Consent to Treatment
 
School Year

Student's Name

 

D. O. B.
Home 
Cell
 
Mother's Name
 

Home Number
Work Cell
 
Father's Name
 
 

Home Number
Work
C
ell
 
Legal Guardian Name                
 
 
Home Number
Work  
Cell
 
Doctor's Name
Office  
After Hours
 
Preferred Local Hospital
 
 
 We, the undersigned parents or legal guardian of the above student, do hereby consent to any x-ray   
 examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be   
 rendered. It is understood that reasonable effort will be made to contact the parent/guardian and the doctor
 listed above before any other physician is called by the school. It is understood that this consent is given in
 advance of any specific diagnosis or treatment which might be required.
 In addition I have read and understand the Emergency Authorization statement and give my full consent
 to the terms found therein. Permission for photo copying of this health record is granted
                                 Present Family Health Insurance Company  
                                                                      
                                                                  Policy Number  
 
 
Are there any known medical conditions that would limit your child from activities?   NO  YES   
 If yes, explain
 
Person to Notify in case of accident or illness if parents are not available:
Name  
Relationship to Student
 
Home Number Work Number 
Cell Number
       Parent / Legal Guardian Signature            
          Date
 






 


 


241 Riverchase Way • Lexington, SC, 29072-9470 • 803-796-0277