APPENDIX C1

CONSENT TO MEDICAL CARE & TREATMENT OF MINOR CHILD

and

EMERGENCY MEDICAL INFORMATION

I hereby give permission that my child, ____________________________, may be given emergency treatment by a qualified staff member at the Gig Harbor Cooperative Preschool. I further authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician, hospital, or aid car attendant when deemed necessary or advisable by the physician or aid car attendant to safeguard my child's health, and I cannot be contacted. I waive my right of informed consent to such treatment.

I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

______________________________	_____________________________

Signature	Phone Number

___________________

Date

Information for: ____________________(child's name)	Birth date:

Regular medications:

Allergies and drug reactions:

Preferred Hospital:

Parent's work phone:	Other number:

Parent's work phone:	Other number: