Create a Website Account - Manage notification subscriptions, save form progress and more.
1) The administration of any treatment deemed necessary by the physician listed above or, in the event the listed physician is not available, or by another physician;
2) The transportation of my child by ambulance to Condell, Lake Forest or Highland Park Hospital, or any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two licensed physicians concurring in the need for such surgery are obtained prior to the performance of such surgery.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
* indicates a required field