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EMERGENCY MEDICAL AUTHORIZATION FORM
School__
Student Name_
Address_
_ Zip _
Telephone_ _
Purpose: To enable parents and
guardians to authorize the provision of emergency treatment for children
when become ill or injured while under school authority, when parents or
guardians cannot be reached.
RESIDENTIAL PARENT OR GUARDIAN
Mother's Name:
_ _ _ p;
Daytime Phone: _ _
Father's Name:
_ _ _
Daytime Phone: _ _ _
Other's Name:
_ _ _ _ ;
Daytime Phone: _ _ _
Pager #:
_ _ __ _
Cell Phone #: _ _ _
Name of Relative or Childcare Provider
_ _ _ _ _
Relationship: _ _ _
Address:
_ _ _ _
Daytime Phone: _ _ _ _
_ _ _ Zip: _ _
-- - - - - - -
PART I: Grant Consent
I hereby give
consent for the following medical care provider and local hospital to be
called:
Physician:
_ _ _ _
Phone: _ _ _ _
Dentist:
_ _ __ _ Phone:
_ _ _
Medical Specialist:
_ _ _ _ Phone:
_ _ __
Local Hospital:
__ __ Phone:
__ __
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 doctors,
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 for such surgery, are obtained prior
to the performance of such surgery.
Facts concerning the child's medical
history, including allergies, medications being taken, and any physical
impairments to which a physician should be alerted:
__ __ __ __ __ __
__ __ __ __ __ __
Date: __ __
Signature of Parent/Guardian: __ __ __ __ __ __
p; p; bsp;
Address: __ __ __ __ __ __ __ __ __ __
p; bsp; p; bsp;
__ __ __ __ __ __ Zip: __ __ __ __
PART 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 the school authorities to take the following
action:
__ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __
Date:
__ __ Signature of Parent/Guardian:
__ __ __ __ __ __ _
Address: __ __ __ __ __ __ __ __
__ __ __ __ __ Zip: __ __ ____ _ |
