Emergency Permission Form

Lets parents and guardians authorize in writing their child's transfer to hospital if an urgent situation occurs, with school details, pediatrician, allergies and health insurance on file. Peace of mind for the family and legal backing for the institution.

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Child's Name

Nombre

Apellido

Gender

Date of Birth

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Child's School

School Phone Number

School Address

Dirección

Ciudad

Estado / Provincia

Código postal

Child's Physician

Nombre

Apellido

Physician's Phone Number

Physician's Address

Dirección

Ciudad

Estado / Provincia

Código postal

Preferred Clinic for Emergencies

List any allergies and medical conditions of child.

Copy of Child's Health Insurance

Max 10 MB per file

Parent/Guardian Name

Nombre

Apellido

Parent/Guardian Phone Number

Parent/Guardian Work Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency Contact Name

Nombre

Apellido

Emergency Contact Phone Number

Emergency Contact Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency medical authorization

Valid From:

Valid To:

Date

Parent/Guardian Signature

Sign here

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