| EMERGENCY MEDICAL CARE This authorizes Michelle Gengenbacher to secure EMERGENCY medical care for my child/children, we hereby authorize all necessary tests, procedures, and/or treatment. __________________________________is the preferred doctor Address________________________________ Phone #________________________________ ______________________________________ is the preferred clinic. Address________________________________ Phone #________________________________ ______________________________________ is the preferred hospital. Address________________________________ Phone #________________________________ We, the parents, assume responsibility for all costs of emergency transportation and care. Mother�s Signature___________________________________________Date_________ Work Phone #________________Cell Phone #_____________Pager_______________ Father�s Signature____________________________________________Date_________ Work Phone #________________Cell Phone #_____________Pager_______________ |
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