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Microsoft word - permission to treat 09-10

Mt. Calvary-Grace Lutheran School
1614 Park Avenue La Crosse, WI 54601-5796 A member of the Wisconsin Evangelical Lutheran Synod “Be strong in the Lord and in his mighty power.” Ephesians 6:10 Permission to Treat
To be presented to the Emergency Department Full Legal Name (first, middle, last) _________________________________________________ Date of Birth __________________________ Grade this school year ______________________ I give my permission to treat my minor son or daughter (or legal guardian) named above for any
emergency medical problem or injury that may be incurred while my son or daughter is under the
care of Mt. Calvary-Grace Lutheran School. This permission extends through May 27, 2010.
I understand that I will be contacted by the Hospital and/or Physician as soon as possible before or after emergency treatment, and the medical illness or injury will be explained to me, and any treatment necessary will be explained to me. Franciscan Skemp Child’s Clinic # __________________ Child’s Physician________________________________________________________________ Parent/Guardian Signature________________________________________________________ Significant medical problems ______________________________________________________ Current medications _____________________________________________________________ Known allergies ________________________________________________________________ Name of insurance company _____________________________________________________ Policy # _______________________________________________________________________ Home phone#(s)___________________________Work phone#(s)________________________ Cell phone#(s)___________________________ Medication Permission (prescription drugs require a different form with a physician’s signature)
The Staff of MCG has my permission to administer the following:
Clarify any: __________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Mt. Calvary-Grace Lutheran School
2009-2010 School Year
School & School-Related Activities
We like to display some of our classroom and extra-curricular activities in our weekly and monthly newsletters and on the MCG school website and must have your permission to do this. Materials may also be posted on area WELS School web sites as well. Returning this signed document in no way ensures that your child’s pictures will be displayed. Thank you for your support and cooperation. I give my permission to publish photos or name (but not both in the same publication) of my child involved in classroom and extra-curricular activities as described in this document. I understand that if students are identified, only their first names will be used. Student’s Name
Student’s Grade
Parent’s Signature Date
If this is not signed, we will not be able to use any pictures that have your child in them.
Mt. Calvary-Grace Lutheran School
2009-2010 School Year
My child has permission to go on walking field trips with his/her teacher and fellow classmates this school year. Examples may include but are not limited to: A trip to Ranison’s Ice Cream Shop Our mission is to provide a Christ-centered education, which supports families in their Christian responsibility to teach their children about Jesus Christ, the only Savior. Student’s Name
Student’s Grade
Parent’s Signature Date


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