Emergency Medical Authorization Form

DOHN COMMUNITY HIGH SCHOOL
Emergency Medical Authorization Form
2009 - 2010
Please fill out this form and return it to your school.
 
Student Name: _____________________________________________Birth Date: ________________ Grade: _____
 
Address:_____________________________________________Apt. _________ Phone No.:____________________
 
City: ________________________________________________ State: ___________________ Zip: ______________
 
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.
 
Parent/Guardian Information:
 
Mother’s Name __________________________________________________Daytime Phone No.:________________
                         First                                                   Last
 
Father’s Name _________________________________________________  Daytime Phone No: _________________
                        First                                                     Last
 
Guardian’s Name: __________________________________________________Daytime Phone No.: _ _____________
                              First                                               Last
 
Name of Relative or Childcare Provider: ______________________________________________________________________________________________
 
Relationship: ___________________________________________  Daytime Phone No.: _______________________
 
Address: ___________________________________________________________________________________________________
                 Street Address                                                                 City                                    State                 Zip
 

PART 1 OR 2 MUST BE COMPLETED
 
PART 1: TO GRANT CONSENT - I hereby give consent for the following medical care provider and local hospital to be called:
 
Physician: ________________________________________________________________ Phone No. ______________
 
Dentist: __________________________________________________________________ Phone No.  _____________
 
Medical Specialist: _________________________________________________________ Phone No.  _____________
 
Local Hospital: ____________________________________________________________ Phone No. _____________
 
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 my child to any hospital reasonably accessible.
                This 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 my child’s medical history, including allergies, medications being taken and any physical impairments to which a physician should be alerted:
 
_______________________________________________________________________________________________
 
________________________________________________________________________________________________
 
Date: ________________ Parent/Guardian Signature:_____________________________________________________
 
Address _____________________________________________________________________________________________________              Street Address                                                                     City                                            State                      Zip
 

PART 2: REFUSAL TO CONSENT – I do NOT give my consent for emergency medical treatment of my child.  In the even of illness or injury requiring emergency treatment, I wish the school to take the following action:
 
_________________________________________________________________________________________________
 
_____________________________________________________________________________________________________
 
Date: ___________________  Parent/Guardian Signature:__________________________________________________
 
Address ________________________________________________________________________________________________________________