EMERGENCY MEDICAL AUTHORIZATION HEATH CITY SCHOOL DISTRICT

Residential Parent / Guardian: _______________________________________________

Student Name: ___________________________________________________________

Mother’s Name: __________________________________________________________

Address: ________________________________________________________________

Father’s Name: _______________________________ Telephone: _________________

Other’s Name: _______________________________ School Attended: _____________

Name of Relative or Child-care Provider: _______________________________________

Name:__________________________________ Address: ________________________

Phone: _________________________________ Relationship: _____________________

Purpose – To enable parents to authorize emergency treatment for student who becomes ill or injured while under school authority, when parents / guardians cannot be reached.

Part I or Part II Must Be Completed

Part I – To Grant Consent

I hereby give consent for the following medical care providers and local hospitals to be called:

Doctor: ______________________________________ Phone: _________________

Dentist: _______________________________________ Phone: __________________

Medical Specialist: ______________________________ Phone: __________________

Local Hospital: __________________________________ ER 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-mentioned 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.

This authorization does not cover major surgery unless medical opinions of two (2) 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: ______________ Parent / Guardian Signature: ________________________________

Part II – Refusal to Consent (Do not complete if you completed Part I)

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

Date: _____________________ Parent / Guardian: _________________________________

Address: ____________________________________________________________________

City: ______________________________________________ Zip: ____________________