Home Tel.______. In case of emergency, if Beth Israel Medical Center is unable to reach any of the numbers listed above,
BETH ISRAEL MEDICAL CENTER EMPLOYEE HEALTH PARENTAL CONSENT FORM FOR MINORS We are considering/reviewing the application of your son/daughter, under the age of 18, for employment/volunteer service at Beth Israel Medical Center. In order to abide by Beth Israel Medical Center policy, it is mandatory for your child to be given a Tuberculosis screening, possibly including a PPD, have a blood test to determine immunization status with regard to Measles (Rubeola), German Measles ( Rubella) and Chicken Pox (Varicella), and for you to sign the Consent for Emergency Treatment ( See last section of this page). Please note: This is an ongoing program, and an updated parental consent form must be signed by you each year, with the original copy kept on file in Employment Health. If your son/daughter tests positive for tuberculosis (PPD Test), he/she will be obliged to have a chest Xray, and to be counseled by a physician on preventative therapy. It is mandated that anyone born after January 1, 1957, have documentation of full immunization against measles. This includes a primary immunization and a recent MMR or Measles ( rubeola) booster. If documentation is not provided, your primary care physician must give a vaccination before you can participate as a volunteer in the Medical Center. I, (Please print your name) ___________________________□ Parent
□ Guardian
Give consent for the above mandatory test screenings and booster vaccination for MMR (Measles, Mumps, Rubella), if applicable in order for my child, (print the name of the minor) ______________________________________________ His/ her Social Security # is _______________________Date of Birth____________ Residing at _____________________________________Apt. # _________________ City___________________________________________ Zip____________________ IN CASE OF EMERGENCY PLEASE NOTIFY: Father’s name_________________________Work Tel. ______________Home Tel. ________ Mother’s name ________________________Work Tel.______________ Home Tel.________ In case of emergency, if Beth Israel Medical Center is unable to reach any of the numbers listed above, I hearby authorize BIMC to render emergency medical care to my son/daughter. Signature of Parent/ Guardian ___________________________________Date_____________
