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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 clinic* Witness State of Kansas Before me the undersigned authority on this day personally appeared known to be the person whose name is subscribed above and acknowledged to me that he/she executed the same for the purpose therein expressed* Sworn and subscribed before me this day of Year. SEAL Notary Public. My Commission expires. ----------------------------------------------------------------------------------Physician Address Phone Hospital Preference Emergency Phone Numbers Home Father work Mother work Do you have Health Insurance Policy Name and Number Do you receive medical assistance Program and Care Number Is child eligible for military medical care I. D. Number Medical Information on Child see attached information Attach this form to the child s health record. 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 clinic* Witness State of Kansas Before me the undersigned authority on this day personally appeared known to be the person whose name is subscribed above and acknowledged to me that he/she executed the same for the purpose therein expressed* Sworn and subscribed before me this day of Year. SEAL Notary Public. My Commission expires. ----------------------------------------------------------------------------------Physician Address Phone Hospital Preference Emergency Phone Numbers Home Father work Mother work Do you have Health Insurance Policy Name and Number Do you receive medical assistance Program and Care Number Is child eligible for military medical care I.

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