Mrs. J. Beth Ciesielski, Executive Director & Founder	94 Lamarck Drive  Buffalo, NY 14226
Bridges for Education, Inc.	TEL 716-839-0180  FAX 716-839-9493
E-Mail: jbc@bridges4edu.org
www.bridges4edu.org

Bridges for Education, inc

Parent Consent form

Consent of Parent for Medical and Emergency Treatment of Name_____________________________________________
State of ___________________County__________________
Date________________
Mr._______________________and_____________________

Being duly sworn, depose and state:
Pursuant to the authority vested in us as parents/guardians of
______________________________DOB________________
authorize a duly licensed physician or surgeon to exercise for us and on our behalf, all our rights and duties with reference to consenting to appropriate medical, surgical or hospital treatment necessary for the medical and emergency care of our daughter/son____________________________.

This includes obtaining the release of any medical records, releasing any records necessary for insurance purposes, and providing or arranging for necessary related transportation. Our daughter's/son's primary physician is:
Name__________________________________
Address________________________________
Telephone______________________________
Fax____________________________________
Email__________________________________

She/he is covered by our family medical plan, name:
_______________________________________
Identification #___________________________
Group Number___________________________

Accompanying this form is the annual physical exam report and a record of immunization and skin testing, which history is correct as far as known to our daughter/son. We give permission for our daughter/son to engage in all activities in connection with Bridges for Education, inc. in   (language program country 

Name)________________________________________Date______________________
Name_________________________________________Date______________________
Name_________________________________________Date______________________

Sworn to me before this _________day of _______ 200_.