Consent administration

Guardian consent records

Record, sign and manage first-aid and referral authorizations in one secure place.

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Guardian consent

Complete the form with the parent or legal guardian.

Consent type

First-aid careRoutine first aid, medication and allergies Psychological referralAssessment, counseling and care coordination

Child and guardian

Child’s full legal name * Date of birth Parent or guardian name * Relationship to child Primary phone Alternate phone Street address City / State / ZIP

Consent election

Opt inAuthorize the selected first aid or referral. Opt outDecline routine first aid or referral at this time.

Emergency exception: Emergency personnel may provide necessary care when there is an immediate risk to the child’s life, health or safety.

Medication authorization

If the guardian selected Opt in, indicate whether designated personnel may administer these commonly used treatments according to label dosage and the child’s weight and age.

Topical antiseptic creams and antibiotic ointments (e.g., Neosporin) Epinephrine for allergies (e.g., EpiPen) Antihistamine (e.g., Benadryl)

Other instructions or restrictions regarding medications

Child allergy information

Mark Yes, No or Unknown for each item. For Yes, describe the reaction or relevant notes.

Additional allergy information

This information will be shared with medical personnel as needed to ensure the child’s safety.

Authorization

Guardian digital signature

Required

Printed guardian name *

Guardian signature

I confirm that I am the parent or legal guardian, that the information provided is accurate to the best of my knowledge, and that I make the selected consent decision voluntarily.

For office or staff use only

Received by Received date Staff initials

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Guardian consent

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Guardian consent records

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Guardian consent

Consent type

Child and guardian

Consent election

Medication authorization

Child allergy information

Referral preferences

Read the complete consent

Guardian digital signature

For office or staff use only

User management

Add a user

Authorized users

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