Stow Parks And Recreation Emergency Medical Authorization
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1STOW PARKS AND RECREATION
EMERGENCY MEDICAL AUTHORIZATION
3760 DARROW ROAD, STOW, OHIO 44224 330.689.5100
Purpose: To enable parents to authorize the emergency treatment for children who become ill or
Injured while under the Stow Parks authority when parents cannot be reached.
CHILD INFORMATION
Child’s Name:_________________________________ Address:______________________________________
Age:_______
Telephone: Home:_______________Cell:__________________Work:_____________________
RESIDENTIAL PARENT OR GUARDIAN INFORMATION
Mother living with family?
Yes_____ No____
Father living with family?
Yes____No__________
MotherName:______________________________
Daytime Telephone:_____________________________
Father Name: ______________________________
Daytime Telephone:_____________________________
Other Name:_______________________________
Daytime Telephone:_____________________________
Name of relative or childcare provider:____________________ Telephone:_____________________________
Address:__________________________________
Relationship:___________________________________
Part I or Part II BELOW MUST BE COMPLETED
PART I (TO GRANT CONSENT)
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor:________________________________________________
Telephone:____________________
Dentist:________________________________________________
Telephone:____________________
Medical Specialist:_______________________________________
Telephone:____________________
Local Hospital:__________________________________________
Telephone:____________________
Urgent Care:___________________________________________
Telephone:____________________
In the event reasonable attempts to contact me at ______________(phone number) or ___________________
_____________ (other parent) at ______________ (phone number) have been unsuccessful, I hereby give
PART I (TO GRANT CONSENT)
my consent for (1) the administration of any treatment deemed necessary by Dr. _____________ (preferred Dr)
Or Dr. ___________________ (preferred dentist), 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 _____________________
(preferred hospital) or any hospital reasonably accessible. This authorization does not cover major surgery
unless the medical opinions of 2 other licensed physicians or dentists, concurring in the necessity for such
surgery are obtained before surgery is performed. Please provide facts concerning the child’s medical history
including allergies, medications being taken and any physical impairments to which a physician should be
alerted: ____________________________________________________________________________________
Signature of Parent:_____________________ Address:____________________________ Date:______________
PART II (REFUSAL OF CONSENT)
I DO NOT GIVE MY CONSENT for any emergency medical treatment of my child. In the event of illness or injury
requiring emergency treatment, I wish the authorities to take no action or to ____________________________
Signature of Parent:_____________________ Address:____________________________ Date:______________
This form must be filled out and on file with the Parks and Recreation Department
before the first day of the program.
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