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COVID-19 Preparedness

Welcome
We Are FSC
- FSC Annual Report
- FSC Form 990
Services
Events
In the News
Contact Us
COVID-19 Preparedness

Release for Emergency Medical Treatment

Fields marked with an * are required.

Child's First Name *

Child's Last Name *

Child's First Name

Child's Last Name

Child's First Name

Child's Last Name

Child's First Name

Child's Last Name

Child's First Name

Child's Last Name

Authorization is hereby given to Family Services Center by

Parent/Legal Guardian First Name *

Parent/Legal Guardian Last Name *

to obtain emergency medical care for the above child(ren).

Name of Primary Medical Caregiver for the child(ren):

First Name *

Last Name *

Medical Caregiver's Address *

Medical Caregiver's Phone Number *

Medical Insurance Company *

Policy Number *

Confirmation Signature *

Date *

Name

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