Emergency Medical Authorization Form printable pdf download

APPENDIX D

EMERGENCY MEDICAL AUTHORIZATION FORM

CYO and School

Lial Catholic School

20___ - 20 ___ School Year

5700 Davis Road

Whitehouse, Ohio 43571

419-877-5167

Student Name________________________________________ Date of Birth ________________Home Phone_____________________

Address__________________________________________________City_________________________State__________Zip________

Purpose--to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured under

school or sport authority, when parents or guardians cannot be reached. FORM MUST BE SIGNED AND DATED IN INK EACH YEAR.

Residential Parent or Guardian:

Mother’s Name___________________________________________________________ Daytime Phone_________________________

Father’s Name___________________________________________________________ Daytime Phone_________________________

Guardian’s Name________________________________________________________ Daytime Phone_________________________

Person to contact if Parent cannot be reached: (REQUIRED)

Name_________________________________________________Phone_______________Relationship__________________________

Allergies ____________________________________________________________Date of last tetanus shot_______________________

Medication being taken___________________________________________________________________________________________

(Name)

(Dosage)

(Times Taken) continue on back if necessary

List of health problems. Example: asthma, vision, epilepsy, diabetes, hearing, bone, or muscle problem, etc:

______________________________________________________________________________________________________________

PART I OR II MUST BE COMPLETED

PART I: TO GRANT CONSENT

If unable to reach parent or guardian, I hereby give consent for the following medical care providers and local hospital to be called:

Physician_______________________________________________________

Phone______________________________

Dentist__________________________________________________________ Phone______________________________

Medical Specialist__________________________________________________ Phone______________________________

Preferred Hospital__________________________________________________Emergency Room 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 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 the performance of such surgery.

*Facts concerning the child’s medical history including date of last tetanus shot, allergies, medications being taken, and any physical

impairments to which a physician should be alerted.

Date______________

Signature of Parent/Guardian_____________________________________________________

Address____________________________________________________________________________

PART II: REFUSAL TO CONSENT

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I

wish the school authorities to take the following action:

__________________________________________________________________________________________________________

Date______________

Signature of Parent/Guardian_____________________________________________________________

Address_____________________________________________________________

Zip__________

Emergency Medical Authorization Form

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