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St. Luke the Evangelist
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Medical Consent Form/
Consentimiento Médico
The maximum number of form submissions has been reached. This form is currently not available.
Will be kept on file for childcare needs, but must be resubmitted on an annual basis.
Se mantendrá en archivo para las necesidades de cuidado de los niños, pero se tiene que volver a presentar
sobre una base anual.
Medical Matters/Asuntos Médicos
I hereby warrant to the best of my knowledge, my child/children are in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.
Certifico por este medio que al mejor de mi conocimiento, mi hijo(a), está en buena salud y asumo toda la responsabilidad por la salud de mi hijo(a). En las declaraciones siguientes, firme solamente aquéllas con las que esté de acuerdo.
Emergency Medical Treatment/Tratamiento Médico de Emergencia
Parent's/Guardian's Name/Nombre del padre / tutor
REQUIRED
Please fill out this field.
Please enter valid data.
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment.
En
caso
de
una
emergencia,
doy
permiso
de
transportar
a
mi
hijo(a)
a
un hospital
para tratamiento
médico
o
quirúrgico
de
emergencia.
Transport to Hospital/Transporte al hospital
REQUIRED
(Select One)
Yes/sí
No
Please fill out this field.
I wish to be advised prior to any further treatment by the hospital or doctor.
Pido ser notificado antes de que el hospital o los médicos hagan cualquier tratamiento adicional.
Advisement prior to any further treatment/Asesoramiento antes de cualquier tratamiento adicional
REQUIRED
(Select One)
Yes/sí
No
Please fill out this field.
In the event of an emergency and you are unable to reach me, contact:/
En el caso de una emergencia y usted no puede llegar a mí, comuníquese con:
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Relationship/Relación
REQUIRED
Please fill out this field.
Please enter valid data.
Family Doctor
Doctor's Name/El Nombre del Doctor
Please enter valid data.
Phone Number
Please enter a phone number.
Children's Medical Information/Información Médica de (los) Niño(s)
REQUIRED
Please fill out this field.
Child/Niño 1
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Date of Birth/Fecha de Nacimiento
REQUIRED
Please fill out this field.
Please enter valid data.
The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma.
Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de
prescripción del médico con el nombre del niño, la dosis y la frecuencia.
Medication(s)/Medicamento(s)
Medical Conditions Information/Información sobre Condiciones Médicas
Childcare personnel will take reasonable care to see that the following information will be held in confidence./
El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
My son/daughter has [Mi hijo(a) tiene]:
Please enter valid data.
Has had an episode the following or has been diagnosed:
REQUIRED
Un episodio de o se le ha diagnosticado:
(Select One)
Seizures/Convulsiones
Asthma/Asma
Diabetic/Diabetes
N/A
Please fill out this field.
Allergic reactions to the following (foods, dyes, latex etc.)
Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
Has had a medical surgery within the last six months?
REQUIRED
Ha sido sometido a cirugía médica dentro de los últimos seis meses?
(Select One)
Yes/Sí
No
Please fill out this field.
Is under doctor's care?
REQUIRED
Está bajo cuidado médico?
(Select One)
Yes/Sí
No
N/A
Please fill out this field.
Has a medically prescribed diet?
REQUIRED
Tiene una dieta prescrita por su médico?
(Select One)
Yes/Sí
No
Please fill out this field.
Has the following physical limitations?
Tiene las siguientes limitaciones físicas
Immunizations current and up to date (including tetanus/diphtheria)
REQUIRED
Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
(Select One)
Yes/Sí
No
Please fill out this field.
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
Child/Niño 2
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Date of Birth/Fecha de Nacimiento
REQUIRED
Please fill out this field.
Please enter valid data.
The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma.
Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de
prescripción del médico con el nombre del niño, la dosis y la frecuencia.
Medication(s)/Medicamento(s)
Medical Conditions Information/Información sobre Condiciones Médicas
Childcare personnel will take reasonable care to see that the following information will be held in confidence./
El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
My son/daughter has [Mi hijo(a) tiene]:
Please enter valid data.
Has had an episode the following or has been diagnosed:
REQUIRED
Un episodio de o se le ha diagnosticado:
(Select One)
Seizures/Convulsiones
Asthma/Asma
Diabetic/Diabetes
N/A
Please fill out this field.
Allergic reactions to the following (foods, dyes, latex etc.)
Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
Has had a medical surgery within the last six months?
REQUIRED
Ha sido sometido a cirugía médica dentro de los últimos seis meses?
(Select One)
Yes/Sí
No
Please fill out this field.
Is under doctor's care?
REQUIRED
Está bajo cuidado médico?
(Select One)
Yes/Sí
No
N/A
Please fill out this field.
Has a medically prescribed diet?
REQUIRED
Tiene una dieta prescrita por su médico?
(Select One)
Yes/Sí
No
Please fill out this field.
Has the following physical limitations?
Tiene las siguientes limitaciones físicas
Immunizations current and up to date (including tetanus/diphtheria)
REQUIRED
Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
(Select One)
Yes/Sí
No
Please fill out this field.
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
Child/Niño 3
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Date of Birth/Fecha de Nacimiento
REQUIRED
Please fill out this field.
Please enter valid data.
The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma.
Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de
prescripción del médico con el nombre del niño, la dosis y la frecuencia.
Medication(s)/Medicamento(s)
Medical Conditions Information/Información sobre Condiciones Médicas
Childcare personnel will take reasonable care to see that the following information will be held in confidence./
El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
My son/daughter has [Mi hijo(a) tiene]:
Please enter valid data.
Has had an episode the following or has been diagnosed:
REQUIRED
Un episodio de o se le ha diagnosticado:
(Select One)
Seizures/Convulsiones
Asthma/Asma
Diabetic/Diabetes
N/A
Please fill out this field.
Allergic reactions to the following (foods, dyes, latex etc.)
Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
Has had a medical surgery within the last six months?
REQUIRED
Ha sido sometido a cirugía médica dentro de los últimos seis meses?
(Select One)
Yes/Sí
No
Please fill out this field.
Is under doctor's care?
REQUIRED
Está bajo cuidado médico?
(Select One)
Yes/Sí
No
N/A
Please fill out this field.
Has a medically prescribed diet?
REQUIRED
Tiene una dieta prescrita por su médico?
(Select One)
Yes/Sí
No
Please fill out this field.
Has the following physical limitations?
Tiene las siguientes limitaciones físicas
Immunizations current and up to date (including tetanus/diphtheria)
REQUIRED
Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
(Select One)
Yes/Sí
No
Please fill out this field.
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
Child/Niño 4
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Date of Birth/Fecha de Nacimiento
REQUIRED
Please fill out this field.
Please enter valid data.
The only medications that will be administered in childcare will be asthma & life saving allergy medications. All medications must come in the original packaging and include doctor's prescription label with child's name, dosage and frequency.
Los únicos medicamentos que se administrarán en el cuidado de los niños serán medicamentos para alergias y para el asma.
Todos los medicamentos tienen que venir en el embalaje original e incluir la etiqueta de
prescripción del médico con el nombre del niño, la dosis y la frecuencia.
Medication(s)/Medicamento(s)
Medical Conditions Information/Información sobre Condiciones Médicas
Childcare personnel will take reasonable care to see that the following information will be held in confidence./
El personal de Cuidado de Niños, tomará el cuidado de mantener esta información confidencial.
My son/daughter has [Mi hijo(a) tiene]:
Please enter valid data.
Has had an episode the following or has been diagnosed:
REQUIRED
Un episodio de o se le ha diagnosticado:
(Select One)
Seizures/Convulsiones
Asthma/Asma
Diabetic/Diabetes
N/A
Please fill out this field.
Allergic reactions to the following (foods, dyes, latex etc.)
Reacciones alérgicas a: (alimentos, tintes, látex, etc.)
Has had a medical surgery within the last six months?
REQUIRED
Ha sido sometido a cirugía médica dentro de los últimos seis meses?
(Select One)
Yes/Sí
No
Please fill out this field.
Is under doctor's care?
REQUIRED
Está bajo cuidado médico?
(Select One)
Yes/Sí
No
N/A
Please fill out this field.
Has a medically prescribed diet?
REQUIRED
Tiene una dieta prescrita por su médico?
(Select One)
Yes/Sí
No
Please fill out this field.
Has the following physical limitations?
Tiene las siguientes limitaciones físicas
Immunizations current and up to date (including tetanus/diphtheria)
REQUIRED
Sus inmunizaciones/vacunas están actualizadas (incluso Tétanos / difteria) :
(Select One)
Yes/Sí
No
Please fill out this field.
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Ustedes deben estar enterados de las siguientes condiciones médicas de mi hijo(a):
Insurance Information/Información sobre Seguro Médico
Insurance/Seguro
I have insurance/Tengo seguro
I do not have insurance/No tengo seguro
Insurance Carrier/Portador del seguro:
Please enter valid data.
Name of insured/Nombre del asegurado:
Please enter valid data.
Insurance Policy Number/Número de Póliza de Seguro
Please enter valid data.
Father's Name/Nombre del Padre
Please enter valid data.
Father's Phone Number/Número de teléfono del padre
Please enter a phone number.
Mother's Name/Nombre de la Madre
Please enter valid data.
Mother's Phone Number/Número de teléfono de la madre
Please enter a phone number.
Parents will be contacted immediately if child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea.
Los padres serán contactados inmediatamente si el niño se enferma con síntomas como dolor de cabeza, vómito, dolor de garganta, fiebre o diarrea.
I Understand/Entiendo
Please select this field.
I am the parent or legal guardian/
Soy el padre o
guardián legal
I Agree/Estoy de Acuerdo
Please select this field.
Date/Fecha
REQUIRED
Please fill out this field.
Please enter a date.
Please leave cell phone on vibrate while attending meeting or event.
Deje por favor el teléfono celular en vibrar mientras que asiste a la reunión o evento.
Submit