hereby grant The Cicada Institute and Sylvie Fanous-Samaan, of 7217 Burlington Ave n, Saint petersburg, Florida 33710, the authority to obtain medical treatment for the following child(ren):
The above care provider(s) are authorized to:
- obtain medical treatment and procedures for the child(ren) as may be appropriate in emergency circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate health care providers.
- obtain routine medical treatment from appropriate health care providers if symptoms of illness occur (e.g., fever, coughing, irregular breathing, unusual rashes, swallowing problems, etc.).
- administer medications as follows:
In case of an emergency, the care provider(s) should first try to contact the parent(s). If the parent(s) cannot be reached, the care provider should then contact the following person(s) in the order listed below:
If the child(ren) become ill, the care provider(s) will first try to contact the parent(s). If the parent(s) cannot be reached, the care provider should contact the following physician:
If the child(ren) need hospitalization, the preferred choice is:
The care provider(s) may provide the physician and other health care providers with the following health insurance information:
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