Living Water Christian School

             3980 Gum Branch Road                                   Jacksonville, NC 28540

               (910) 938-7011              (910) 938-7017            Fax (910) 938-7025

 

 

                              Authorization for Emergency Care to Minor(s)

 

Complete One for Each Student Enrolled at LIVING WATER CHRISTIAN SCHOOL

 

 

Student Name (Last):                                                            First:                

 

Grade:

 

 

Home Phone:

 

Health Insurance With:

 

Mother’s Work Phone:

 

Policy Holder:

 

Father’s Work Phone:

 

Policy Number:

In case of emergency illness or accident, the child is given first aid and then the parents are notified.  If the parents

or the child’s doctor cannot be located, the child will be taken to the Emergency Room of our choice.  The School

 does not assume responsibility for the payment of hospital, doctor or ambulance fees.

 

I/We the undersigned, parent(s) or legal guardians of the minor listed below:

                                                                                                  

                       (Minor’s Name)                                                         (Birthdate)

do hereby authorize any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any

physician or dentist licensed by the State and hospital service that may be rendered to said minors under the

general, specific, or special consent of an acting agent of the school, the temporary Custodian of the minor, whether

such diagnosis or treatment is rendered at the office of the physician or dentist, or at a hospital licensed by the State. 

I/We authorize the physician or dentist to call in any necessary consultants, in his/their own discretion.  We further

authorize said physician or dentist to exercise his/their discretion in authorizing the disposal of any severed tissue

or member.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given

to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise

his/their best judgement as to the requirements of such diagnosis of medical or dental or surgical treatment.

 

To be signed and witnessed during registration

 

This consent shall remain effective for the duration of the student’s enrollment at LIVING WATER CHRISTIAN SCHOOL unless

sooner revoked in writing, delivered to said physician or dentist of the said persons entrusted with the custody, care and control of

said minor children.

 

 

Date:

 

Father’s (Guardian) Signature:

 

 

 

Mother’s (Guardian) Signature:

 

 

Witness Signature (Other than Custodian(s):

 

Rev. January  24, 2003