Please list at least one(1) emergency contact.

This form allows parents and guardians to authorize the provision of emergency treatment for the child(ren) named who becomes ill or injured while under program authority when parents or guardians cannot be reached. In the event reasonable attempts to contact have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by the doctor or dentist listed above, or if unavailable, another licensed physician or dentist.

I agree to pay all costs and fees as secured or authorized under this consent.

... prohibits discrimination against its families, employees, or applicants for employment on the basis of race, color, national origin, age, disability, sex, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status.