Imaginations Learning Academy

Emergency Medical Consent Form

I (We), _______________________________, hereby consent for my (our) child, ________________________, to be given emergency treatment (including, but not limited to, CPR & First Aid) by a qualified staff member of Imaginations Learning Academy.

I (We) also give permission for my (our) child to be transported by ambulance, aid car, or staff car to an emergency center for treatment if so needed.

Further, I (We) consent to x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to my (our) child by licensed physicians and/or hospital staff. Such care will be rendered only when deemed immediately necessary or advisable to safeguard my (our) child’s health.

Should my (our) child receive emergency treatment and/or transportation, I (We), agree to pay all costs incurred.

Child’s physician: ______________________Phone Number: ____________

Physician’s address: ___________________________________________

Child’s Dentist: _______________________Phone Number: ____________

Dentist’s Address: ____________________________________________

Preferred Hospital: ____Sandlake ____Arnold Palmer ____FL Hospital Kiss.

____Celebration Health _____Osceola Regional

Insurance Company: _____________________Policy Number: ___________

Known Allergies: ______________________________________________

Date of Last DPT (Tetanus) Shot: __________________

Mother’s Signature: _____________________________Date: __________

Father’s Signature: _____________________________Date: __________