TO WHOM IT MAY CONCERN:

I hereby authorize, give consent, and assume financial responsibility for any dental services, medical or surgical care, eye care, or routine tests to be performed on my child while he/she is at the Caliente Youth Center, Caliente, Nevada, or when said services are deemed necessary or advisable by the attending physician. I also consent to the administration of whatever anesthetics are advisable or necessary. I further consent to have my child's medical history report sent to the Infirmary at the Caliente Youth Center or to any treatment facility which is addressing the emergency medical needs of my child.

MEDICAL/DENTAL INSURANCE INFORMATION

Insured’s Name on Policy
Insurance Company Name
Insurance Company Address
Policy Number
Group Number
Insurance Claims or Contact telephone number
Insured’s Social Security Number (last 4 only)
Insured’s Date of Birth
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Telephone number
Parent/Guardian Home Address
Date Submitted
All Information to be verified by DCFS staff before activation