LIC 627 Consent for Emergency Medical Treatment


State of California – Health and Human Services Agency California Department of Social Services
LIC 627 (9/08) (CONFIDENTIAL)

CONSENT FOR EMERGENCY MEDICAL TREATMENT- Child Care Centers Or Family Child Care Homes

 


AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

Technique Adventure & Activity 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

CHILD’S NAME:  

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:

 

PARENT OR AUTHORIZED REPRESENTATIVE

HOME ADDRESS

HOME PHONE:  

WORK PHONE:  

 

Leave this empty:

Signature arrow

Signed by Kathy Olvera
Signed On: January 9, 2021

Signature Certificate
Document name: LIC 627 Consent for Emergency Medical Treatment
lock iconUnique Document ID: 68b2dd5ff7286aad74f5542d85ad70adfcf65905
Timestamp Audit
January 9, 2021 6:57 pm PSTLIC 627 Consent for Emergency Medical Treatment Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93