Emergency Medical Authorization Form

Student Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

School Messenger Phone(Required)

(The one number you would like to be contacted for the following: notification of absence, closings or delays, or various situations.)

Email(Required)

Parents(Required)

Married

Divorced

Separated

Other

If divorced/separated/other, who is residential parent?

First Last

Non-resiedential parent

First Last

Address of non-residential parent

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, or non-emergency incidents when parents or guardians cannot be reached.

Mother/Guardian Name

First Last

Home Phone

Work Phone

Cell Phone

Father/Guardian Name

First Last

Home Phone

Work Phone

Cell Phone

Other's Name

First Last

Home Phone

Work Phone

Cell Phone

Please list facts concerning the child’s medical history, including allergies, medication being taken, and any physical impairment to which a physician should be alerted.

Allergies (Please list all allergies, type of reaction, and treatment)

Medical Condition(s)

Medications/Treatments

Does your child have any condition that could be life threatening?

Yes

If yes, please explain

Please select approved medications to give out

Acetaminophen (Tylenol) 650 mg

Ibuprofen (Advil) 400 mg

Calcium Carbonate (Tums)

Signature(Required)

Complete only one of the following (Section I or II)

Section I: Consent for Treatment

I hereby give consent for the following medical care providers and local hospital to be called.

Do you have a primary care physician?

Yes

If so, have you seen your primary care physician in the last year?

Yes

If you do not have a primary care physician, can the school refer you to one?

Yes

Preferred Physician

Physician Office Phone

Preferred Dentist

Dentist Office Phone

Preferred Eye Specialist

Eye Specialist Office Phone

Medical Specialist

Medical Specialist Office Phone

Preferred Hospital

ER Phone

Record of last Tetanus Shot

In the event reasonable attempts to contact me have been unsuccessful. I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

The authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity of such surgery, are obtained prior to the performance of such surgery.

Signature

DO NOT COMPLETE SECTION II IF YOU COMPLETED SECTION I.

SECTION II: Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment:

I wish for the school authorities to take the following actions