Emergency Medical Consent Form
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
PRESBYTERIAN EARLY LEARNING CENTER
TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR:
THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
Child has the following medication allergies. If none, please enter "none".
Date Format: MM slash DD slash YYYY
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Or Phone 1
Or Phone 2
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PELC (Presbyterian Early Learning Center)
728 W. Fremont Ave, Sunnyvale, CA 94087
· 408-245-2253 ·
PELC is an outreach of the
Sunnyvale Presbyterian Church
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