RSVP 2 — Fervent Care Child Care

First Aid Care

For Emergency Medical and Staff authorization First Aid Care

I hereby authorize the staff and directors representing Fervent Care Child Care and Christian Academy to give consent for any and all necessary emergency medical, life saving and first aid treatment for (insert Childs name) while he/she is in the custody of fervent Care Child Care and Christian Academy.

I hereby subscribe and confirm on this day (insert date. In the state of Indiana and the city of Indianapolis my permission for Fervent Care Child Care and Christian Academy to do what is medically necessary to save my child's life.

Signature of Parent/Guardian :

First Name

Last Name

Date

MM

DD

YYYY

Signature of Intake Personnel

First Name

Last Name

Date

MM

DD

YYYY

List all allergies and any special precautions and treatment indicated for these allergies :