ࡱ                >  	               ?          A          >    '`	               -   bjbj                  	 *$            '                                                               n      n  n      n      n      n      n                                 8          D         P!     >      >      >      >      >      >      >      >                         E              $   <"  h  $  j                         n      >                      >      >      >      >                     n      n      >              >      
!                       >  p   n      >      n      >                                                                          >                                        n      n                                                                    >      2     t=76                |                      !  0   P!            %      *  X   %                                                                                    %              n        $   >      >            >      >                                      >      >      >                                                      X                                   >      >      >      P!      >      >      >      >                            $
                                                n      n      n      n      n      n      
!                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         NAME OF AGENCYADDRESSTELEPHONEChilds Name:Birthdate:Social Security #:MEDICAL CARE AND EMERGENCY HOSPITALIZATION:I hereby authorize and grant permission for routine medical treatment (including routine exams, immunological services, lab studies, etc. as considered normal and necessary) and/or emergency hospital admission for the above named child, who is in placement at ____________________,  when such services are deemed necessary by a duly qualified physician or other duly qualified personnel.  I understand that I will be kept fully informed of special medical problems and needs.  Whenever possible, consent from the legal guardian will be sought for specific emergency procedures.Signature of Parent/Guardian:Relationship:Witness:Date:MEDICATION ADMINISTRATION:I hereby authorize and grant permission for qualified personnel of ________________________to administer to the above named child, who is in placement at _________________________,medications, including Psychotropic medications, as prescribed by a duly qualified physician and non-prescription medications as needed.  I understand that I will inform _________________________ personnel in writing of any medications (including medications which may cause an allergic reaction) that may not be administered to the above named child.Signature of Parent/Guardian:Relationship:Witness:Date:DENTAL CARE:I hereby authorize and grant permission for routine dental care (including the administration of a local anesthetic for the filling of cavities) for the above named child, who is in placement at __________________________.  I understand that I will be informed of any emergency or special dental needs.Signature of Parent/Guardian:Relationship:Witness:Date:RPU-Medconsent (07/2009)                                                                                                                                                                                                                      V    	  	    '  j        g      >      T  n        	            +  -                                                                                                                                                                                                                                                                                           hv1  j    h_M Uh_M 56>*h_M 56 	h_M >*	h_M 5h_M        !  "  #  1  2  3  >  ?  @                                                                                                                          f                          E  kd_   $$If   l 0 ,"                  ~                                        4 
l a   E  kd    $$If   l 0 ,"                  ~                                          4 
l a    $If         $a$      ,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                @  S  T  U  V      
  
  
  
  
  
                                                                                                                          k                               E  kd9  $$If   l 0 
," R                 F                                          4 
l a      E  kd   $$If   l 0 ,"                  ~                                      4 
l a    $If    
  
  
  
                                                           m                                                                                                                                    E  kd  $$If   l 0 
," R                 F                                        4 
l a   E  kd  $$If   l 0 
," R                 F                                        4 
l a    $If      	  
    &  '      =  >  \  ]  ^                                                                                                                                      k                   E  kd  $$If   l 0 
," R                 F                                          4 
l a    $If       E  kdr  $$If   l 0 
," R                 F                                      4 
l a   ^  l  m  n  w  x  y                                                                  m                                                                                                                   E  kd  $$If   l 0 
," R                 F                                        4 
l a   E  kd>  $$If   l 0 
," R                 F                                        4 
l a    $If              T                                                                                                                            k                                           E  kd  $$If   l 0 
," R                 F                                          4 
l a    $If       E  kd  $$If   l 0 
," R                 F                                      4 
l a                                                     m                                                                                                                                                     E  kdQ  $$If   l 0 
," R                 F                                        4 
l a    $If    E  kd  $$If   l 0 
," R                 F                                        4 
l a             
            *  +  ,  -                                                                                                                                                                                                                                                                                        $a$gd3     E  kd  $$If   l 0 
," R                 F                                      4 
l a   ( / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ] $$If     !v h5 5~#v #v~:V l      5 5~4    k $$If     !v h5 5~#v #v~:V l      5 5~/     4    k $$If     !v h5 5~#v #v~:V l      5 5~/     4    ] $$If     !v h5 R5F#v R#vF:V l      5 R5F4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    ] $$If     !v h5 R5F#v R#vF:V l      5 R5F4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    ] $$If     !v h5 R5F#v R#vF:V l      5 R5F4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4    k $$If     !v h5 R5F#v R#vF:V l      5 R5F/     4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             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 P a r a g r a p h   F o n t     V i@ V          T a b l e   N o r m a l     :V   4   4 
l a      ( k@ (           N o   L i s t         4 @  4   3    H e a d e r      !   4  @ 4   3    F o o t e r      !   H @ H   3    B a l l o o n   T e x t      CJ OJ QJ ^J aJ     -    $             !   "   #   1   2   3   >   ?   @   S   T   U   V                                    	  
    &  '      =  >  \  ]  ^  l  m  n  w  x  y              T                                    
            *  +  .      0                        0                        0                        0                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                        0                        0                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                        0                        0                        0                        0                        0                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                        0                        0                        0                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                   0                      0                     0                      0                     0                      0                     0                      0                     0                     @  0                    0                      0                          2   3   ?   @   T   U                  	  ]  ^  m  n  x  y                      .   0                     0                 ^% 0! X        `q
      0                _                       0                L_0*                   @ 0                _              0             	   _               @      0
                |(               	     0                \                  
  0                ,,                      0                d,    0                 0                (_    0                  0                `_     @ 0            0                _         	               0                .       !      "      #  0                /$      (      )      *  0                H/   1      2      3     0                    	             	                  &   &   &   )      -        @  
    ^        -  	                           ,  
       3   <               
                +  .                                                
            +  .   3  3  3                                 
          )  .                                
            +  .                                   3 _M v1     "   #   1   2   3   >   ?   @   S   T   U                              	    =  >  \  ]  ^  l  m  n  w  x  y                                    .      3                   3                                                       3                        @\\ssms9k5\MOSS9K6X (R5939) Ne01: winspool Dell Color Laser 5110cn PS \ \ s s m s 9 k 5 \ M O S S 9 K 6 X   ( R 5 9 3 9 )              S  
od   X  X   L e t t e r                                                                                                       PRIV0                                                                                       '''  '                                         H \K hC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 H  DFBF01401#  WKlFopk2                                                               1 . 0 0 8   |P r i n t P r o c C a p s _ E M F                                                                                                                                                                                  \ \ s s m s 9 k 5 \ M O S S 9 K 6 X   ( R 5 9 3 9 )              S  
od   X  X   L e t t e r                                                                                                       PRIV0                                                                                       '''  '                                         H \K hC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 H  DFBF01401#  WKlFopk2                                                               1 . 0 0 8   |P r i n t P r o c C a p s _ E M F                                                                                                                                                                                           خ                         -  P   @      U n k n o w n                                   G  :                    T i m e s   N e w   R o m a n   5                       S y m b o l   3&  :                    A r i a l   5&  z a               T a h o m a   "      h    ׆׆׆                           r!                                                                                                                                                                                                                                                                                                                         x x 4    d                                                                                2                             HX    	 ?    3    :                         N A M E   O F   A G E N C Y        V i k i   F a g y a l  r o e t u w b                                                                                                                                                                                                                                                                                             Oh +'0                                                  	          
   4     @     L     X     d     l     t     |             NAME OF AGENCY                  Viki Fagyal                 RPU Medconsent.dot        roetuwb       2         Microsoft Office 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Department of Social Services                      '                                     NAME OF 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                                               1 T a b l e                                                                                                   %      W o r d D o c u m e n t                                                                                        *$       S u m m a r y I n f o r m a t i o n                           (                                     .           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        6           C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
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