2022-23 TPP Emergency Medical Agreement - Trinity Presbyterian Preschool

Parents Name (First and Last Name) *

Names of children attending TPP in 2022-23 *

Date *

I am the parent/guardian of the children listed above do hereby give permission to Trinity Presbyterian Preschool and Trinity Presbyterian Church, to secure and authorize such emergency care and/or treatment as above named child(ren) might require while under the supervision of said childcare provider. I further authorize said childcare provider to administer emergency care/treatment as required until medical assistance is available. I also agree to pay all costs and fees contingent of any emergency medical care and/or treatment for said child as secured or authorized under this consent. Note: Every effort will be made to notify parents immediately in case of an emergency. In the event of an emergency, it will be necessary to have the following information.

Names of people child lives with: *

Any known allergies or medical conditions of child? *

Child's Physician *

Physician Phone Number *

Name of Company *

Name of Member *

Policy Number *

Group Number *

Company Phone Number *

Phone