Columbia Adventist Academy
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Emergency Consent to Treat


   Columbia Adventist Academy
Emergency Consent to Treatment
School Year

Student's Name


D. O. B.
Mother's Name

Home Number
Work Cell
Father's Name

Home Number
Legal Guardian Name                
Home Number
Doctor's Name
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:
Relationship to Student
Home Number Work Number 
Cell Number
       Parent / Legal Guardian Signature            



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