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Get CG5484H.pdf. Child Development Services-Medical Consent Form - Uscg

Ll out all spaces. If an item is not applicable, put N/A in the space. This form is a legal document and must be filled out completely and correctly to be valid. TO: HEALTH CARE PROVIDER I, , am the parent or legal guardian of the child named below, and entitled to medical care at your facility/practice. Child s Full Name: , Age: Address: , Phone: , ID Card # , Exp. Date (Sponsor s Name) (Employee ID Number) (Duty Station) I do appoint the Child Development Center Director.

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