Transportation Consent Form

I __________________________ (name of parent), give permission for Gina B. Ahrens to take

my child, _____________________________ (name of child,) in the car as necessary.

The provider is required, by me, to use safety approved car seats when necessary

to transport my child. All trips must be approved my me in advance of said trip.

_________________________________

Medical Emergency Treatment Consent Form

I __________________________ (name of parent), give permission for Gina B. Ahrens to

provide all necessary emergency medical, dental or other care

for_____________________________ (name of child). This care may be given under whatever

conditions are necessary to preserve the life, limb or well being of my dependant.

The provider is required to try to contact me, the other parent or legal guardian

at one of the below telephone numbers. At no time will the provider attempt to drive the sick or

injured child to an emergency medical facility.

A photocopy of my child's insurance information is attached.

Parent or Legal Guardian's Name_________________________________________

Telephone Numbers______________________________________(day)

Telephone Numbers______________________________________(evening)

Telephone Numbers______________________________________(Beeper or other)

Parent or Legal Guardian's Name_________________________________________

Telephone Numbers______________________________________(day)

Telephone Numbers______________________________________(evening

Telephone Numbers______________________________________(Beeper or other)

_________________________________

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