Emergency Medical Authorization

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

RESIDENTIAL PARENT OR GUARDIAN:

Mother___________________________SS#______________Daytime Phone_______________

Father___________________________SS#______________Daytime Phone_______________

Other Name________________________________________Daytime Phone_______________

Name of Relative or Childcare Provider______________________________________________

Address_________________________________Phone__________________________Relationship____________________

PART 1 OR II MUST BE COMPLETED

PART I- TO GRANT CONSENT

I hereby give consent for the following medical care proviers and local hospital to be called:

Doctor______________________________ 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 doctor, or, in the event the designated practitioner is not available, by another licensed physician or dentist: and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless 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 OR GUARDIAN_____________________________

Address:_______________________________________________________________________
Street/po # City state zip

PART II- TO GRANT CONSENT

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treament, I wish the school authorities to take the following action:

__________________________________________________________________________________

DATE____________________ SIGNATURE OF PARENT OR GUARDIAN_____________________________

Address:_______________________________________________________________________
Street/po # City state zip

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Last update: Saturday, January 31, 2004 at 8:39:11 PM.

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