
CCL 010 Rev. 7/2012 Kansas Department of Health and Environment Bureau of Family Health 1000 SW Jackson Suite 200 Topeka KS 66612-1274 Child Care Unit Phone 785-296-1270 Fax 785-296-0803 Foster Care Unit Phone 785 296-1270 Fax 785 296-7025 Website www. kdheks. gov/kidsnet/ Consult local hospital to be sure this form is acceptable. Written permission of the parent guardian or legal custodian for emergency medical treatment must be on file at facility for each child on a form that meets the requirements of the hospital or clinic where emergency care will be given* License or Certificate In order to meet all legal requirements I hereby authorize and/or who is are representative s of Child Care Facility to give consent for any and all necessary emergency medical care for my child Name while said child is in said individual s custody between the dates of and Month Day Year Signature of Parent or Guardian Parent s signature needs notarization or witnessed if required by local hospital or cli....
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How to fill out the Ccl 010 form online
Filling out the Ccl 010 form is essential to ensure that emergency medical care can be provided for your child in a timely manner. This guide will provide you with clear and concise instructions on how to complete the form online, making the process straightforward and user-friendly.
Follow the steps to complete the Ccl 010 form online.
- Press the ‘Get Form’ button to access the Ccl 010 form and open it in the online editor.
- Begin by filling in the license or certificate number at the top of the form. Ensure that this information is accurate, as it is critical for the legal documentation.
- Next, provide the names of the authorized representatives from the child care facility who may consent to emergency medical treatment for your child. This ensures that the right individuals are recognized for this responsibility.
- Indicate the name of the child for whom this authorization is being provided. It is important to correctly enter the child's full legal name.
- Fill in the dates during which the authorized representatives will be responsible for the child. Use the designated fields to specify the start and end dates.
- Sign the form as the parent or guardian in the designated signature field. Note that your signature may need to be notarized or witnessed, depending on local regulations.
- If applicable, fill in the witness section, including their name and signature, to validate the authorization.
- Complete the physician's information, including their name, address, and contact number. This ensures the care provider has essential contact information in emergencies.
- Gather and input emergency contact numbers for family members, including both parents' work numbers, to facilitate immediate communication if needed.
- Fill in health insurance details, if applicable, including the policy name and number—this is vital for any medical care your child may require.
- Lastly, make sure to attach this completed form to your child's health record, as both documents need to be taken to the emergency room in case of an emergency.
- After completing all the sections, you can save the changes, download the form, or print it for your records or submission.
Complete your documents online today for a streamlined experience.
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