Cedarbrook Adventist Christian School

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Consent to Treat Form

Continuing Consent for Treatment Form

Cedarbrook Adventist Christian School (CACS)


I, the undersigned, legal parent or guardian of ________________________________,

                                                                                            (Student’s Name)

a minor student at CACS, do give consent to any emergency treatment necessary in the event of an accident while at school or on a school sponsored field trip. I understand that the teaching staff will do everything possible to reach me by phone if an accident occurs, but if I cannot be reached, this form gives my permission for the school to seek medical help for my child. Minor injuries will be tended to by the school staff.


If an accident occurs locally where my child needs medical treatment, i would prefer that they be seen by our family physician, Dr. __________________________. The physician's office phone number is ______ - ______ - _________. If this physician is not available, I understand that in the event of an emergency, it will be necessary to seek the services of another physician at a local hospital or emergency clinic.


I hereby authorize any hospital, physician, or other person who has attended to or examined my child to furnish to the General Conference of Seventh-day Adventist Insurance Service any information regarding the treatment received, if school insurance is used to pay for the medical treatment. This will not be necessary if the family’s private insurance carrier is used.


A photocopy of this authorization shall be considered as effective and valid as the original.


__________________________          _______________________________________

                    (Date)                                                           (Legal Parent/Guardian Signature)