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In the event I
cannot be contacted during a medical emergency I consent to the medical, dental
and hospital treatment and procedures to be performed for my child(ren) by a
licensed physician or hospital when deemed immediately necessary.
Listed below is
my medical and dental insurance information for my child(ren)
_______________________________________________________________
Medical (please list all
information that is on your insurance card or provide copy of card)
Dental (please list all information that is on your
insurance card or provide copy of card)
In addition, all
costs involved in emergency treatment and/or the cost of transportation by
ambulance is the responsibility of the parent/guardian of the injured/ill
child. The childcare provider or any members of the childcare providers family
will not be held liable for any injury/illness of any parent/guardian or child
while on the premises of the childcare providers home, while the child is in the
company of the childcare provider during field trips or any outings away from
the childcare providers home.
_________________________________
_________________
Signature of
Parent/Guardian Date
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