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FORM 2 – Emergency Release and Waiver of Liability

    EMERGENCY RELEASE AND WAIVER OF LIABILITY

    Fields with an asterisk * are required:


    Child(ren’s) Full Name(s):

    In the event my child(ren) listed above becomes ill or sustains any injury while in the care of St. Philip Early Learning Center and it is not possible to reach me or another individual authorized by me to give consent to medical treatment, I hereby grant to St. Philip Early Learning Center and its authorized agents and employees, the power to give consent, on my behalf, to any licensed physician/dentist/surgeon/hospital to whom my child is taken in the event of such an emergency to administer treatment such licensed physician/dentist/surgeon/ hospital believes necessary for the relief of pain and to preserve my child’s life and health. I will be responsible for all expenses incurred by such an illness or injury, including emergency transport via ambulance and any hospital charges.

    I, , hereby give my consent and agree to release, indemnify and hold harmless the St. Philip Early Learning Center, its agents and employees from any claim arising from any injury or illness to my child during or after participation with the St. Philip Early Learning Center.

    * Type in name of Parent/Legal Guardian

    * Date

     

    * Physician’s Name

    * Address

    * Phone

     

    * Family Dentist’s Name

    * Address

    * Phone

    Hospital of Choice:

    Children's Hospital at Highlands RanchSky Ridge Medical CenterSwedish HospitalLittleton Adventist HospitalClosest

     

    * Address of Hospital Choice

    * Phone # of Hospital Choice