Emergency Medical Authorization Form
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1Emergency Medical Authorization Form
Union Local Athletics
Building
Grade
Homeroom Teacher
Student Information
Student Name
Student Birth Date
Parent/Guardian
Student Address
Home Phone
Cell Phone
Health Information
Allergies
Preferred treatment for allergies
(If this includes medication of any type, please send a supply to the school nurse)
Chronic medical problems
Medication taken every day
Prior hospitalizations/surgeries
Other health information the nurse should know
(Please attach note if health history is lengthy)
Contact Information (Should your child become ill at school and we can’t reach the parent/guardian)
Please list contact information in the order you would like the calls to be made:
Name
Relationship
Phone Number
1.
2.
3.
Insurance Information
My child does not have insurance
My child does have insurance.
Name of the insurance company
Policy Number
I hereby give consent for the following medical care providers and local hospital to be called:
Physician
Phone(
)
Dentist
Phone(
)
Emergency Room
Local Hospital
Phone(
)
I give permission for school personnel to administer Tylenol or Tums as needed. Yes ___ 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 the
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 performance of such surgery.
Revised 10/3/16
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Parent category: Medical