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Collects program registration general information for the child, including guardianship contacts, emergency notification numbers, health history, allergies and chronic conditions, operations or serious injuries with dates, last tetanus shot, and current medications. Includes medical insurance information fields and an authorization section granting routine care, ordering tests and X-rays, releasing relevant records, arranging transportation, and allowing emergency treatment or hospitalization if guardians cannot be reached. Includes safety and wellbeing responsibilities and signature.","College of the Holy Cross Required for the Policy of Protection of Children  \nMedical Treatment Authorization Form  \nGeneral Information  \nProgram Name:   Name:   Address  Date of Birth:   Age:   Sex:   Grade:   First Parent/Guardian Name:   Relationship:   Best Phone (  )   Work Phone: (  )   Second Parent/Guardian Name:   Relationship:   Best Phone (  )   Work Phone: (  )   If not available in an emergency, notify:  \n1   Phone No.:   (  )   \n2   Phone No.:   (  )   \nHealth History  \nAny recurring illnesses or chronic conditions that could impact the child’s participation in this program, including but not limited to allergies and/or medical or mental health conditions:  \n___________________________________________________________________________________  \nOperations or Serious Injuries (with dates):  \n___________________________________________________________________________________  \nLast Tetanus Shot:    \nCurrent Medications (Name / Dosage / Frequency / Reason)  \nCollege of the Holy Cross Required for the Policy of Protection of Children  \n[ Note: The College does not distribute medications to children. If you have any questions or concerns or require a reasonable accommodation, please contact the Program Director:   ]  \nMedical Insurance Information  \nInsurance Company:  \n____________________________________________________________________________  \nInsurance Company Phone Number:  \nPolicy Number:  \n______________________________________________________________________________  \n-------------------------------------------------------------------------------------------------------------------------------  \nAUTHORIZATION FOR MEDICAL SERVICES  \nI, the parent/guardian of the child identified above, consent to my child’s participation in the Program for which we are registering. I confirm that my child does not have any conditions that would prevent him/her from safely participating in and meeting the requirements of this program. I understand and agree that my child is required to maintain appropriate medical insurance throughout the Program and I agree to maintain such coverage. I assume full responsibility for the arrangement and cost of all medical services arranged for by the College of the Holy Cross, pursuant to this agreement. I understand that the College’s policy is that it will not administer any medication, even over the counter, medication for my child.  \nI give permission to the College of the Holy Cross to provide routine health care; to order X-rays, routine tests, and treatment; to release any records necessary as related to such treatment; and to provide or arrange necessary related transportation for my child as it relates to the child’s medical/mental health needs. In the event I cannot be reached in an emergency, I hereby give permission to the medical provider selected by the College to secure and administer treatment, including hospitalization for the child identified above.  \nI understand and agree that I have a responsibility to ensure the safety and well-being of all participants by keeping my child home in the event s/he is not feeling well or has been exposed to a communicable illness. I understand that the College has the right to refuse to admit and/or may dismiss a person who does not meet acceptable health conditions (such as, in the event of a temperature, contagious disease, etc. ) . In the event I am contacted for such reasons, I agree to pick up my child within thirty (30) minutes of such notice.  \n\n| Printed Name of Parent/Guardian | Date |\n| --- | --- |\n\nSignature of Parent/Guardian","cbCaidMZGArw0Wvi","https://ap.wps.com/l/cbCaidMZGArw0Wvi","pdf",97168,2,"English","en",105,"# General Information\n## Health History\n## Medical Insurance Information\n# Authorization for Medical Services\n## Parent/Guardian Signature","[{\"question\":\"What information must be completed in the form for the child and guardians?\",\"answer\":\"The form requests the program name, the child’s basic details (name, address, date of birth, age, sex, grade), and both parent/guardian names, relationships, best phone numbers, and work phone numbers, plus emergency notification contacts.\"},{\"question\":\"What does the authorization allow the College to do?\",\"answer\":\"It authorizes routine health care, ordering X-rays and routine tests and treatments, releasing necessary records related to care, and providing or arranging transportation related to the child’s medical or mental health needs.\"},{\"question\":\"What happens if a parent/guardian cannot be reached in an emergency?\",\"answer\":\"The parent/guardian grants permission for the medical provider selected by the College to secure and administer treatment, including hospitalization, for the identified child.\"}]","Medical Treatment Authorization Form - Child Protection | PDF",1789633920,{"code":4,"msg":75,"data":76},"ok",{"site_id":69,"language":68,"slug":77,"title":59,"keywords":78,"description":60,"schema_data":79,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"medical-treatment-authorization-form-child-protection","",{"@graph":80,"@context":133},[81,96,116],{"@type":82,"itemListElement":83},"BreadcrumbList",[84,88,90,93],{"item":85,"name":86,"@type":87,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":89,"name":10,"@type":87,"position":66},"https://docshare.wps.com/template/",{"item":91,"name":36,"@type":87,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":87,"position":95},"https://docshare.wps.com/template/medical-treatment-authorization-form-child-protection/288787/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/medical-treatment-authorization-form-child-protection/288787.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":85,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":113,"interactionType":114,"userInteractionCount":15},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"What information must be completed in the form for the child and guardians?","Question",{"text":123,"@type":124},"The form requests the program name, the child’s basic details (name, address, date of birth, age, sex, grade), and both parent/guardian names, relationships, best phone numbers, and work phone numbers, plus emergency notification contacts.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What does the authorization allow the College to do?",{"text":128,"@type":124},"It authorizes routine health care, ordering X-rays and routine tests and treatments, releasing necessary records related to care, and providing or arranging transportation related to the child’s medical or mental health needs.",{"name":130,"@type":121,"acceptedAnswer":131},"What happens if a parent/guardian cannot be reached in an emergency?",{"text":132,"@type":124},"The parent/guardian grants permission for the medical provider selected by the College to secure and administer treatment, including hospitalization, for the identified child.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1790036672]