Health Form B - Emergency Medical Authorization
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1
2hEalth alErt
p —25
EmErgEncy mEdical authorization
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. This information may be shared with the educational team to best meet your child’s needs.
Student Name ______________________________________________
Phone # ___________________________ Bus # __________________
Address __________________________________________________
School District _____________________________________________
_________________________________________________________
School Attending ___________________________________________
Address Change Y N Birth Date ____________________________
Sex M F Grade _______ Home Room _______________________
residential parent or guardian
Mother __________________________________ Day Ph # ________________________________ Cell # _______________________________
Email _____________________________________________________________________ Pager # _____________________________
Father __________________________________ Day Ph # ________________________________ Cell # _______________________________
Email _____________________________________________________________________ Pager # _____________________________
Other Name _____________________________ Day Ph # ________________________________ Cell # _______________________________
Name of Relative or Childcare Provider _______________________________________________________________________________________
Address __________________________________________________
Phone # ___________________________________________________
__________________________________________________________
Relationship _______________________________________________
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor ____________________________________________________
Phone # ___________________________________________________
Dentist ____________________________________________________
Phone # ___________________________________________________
Medical Specialist __________________________________________
Phone # ___________________________________________________
Hospital __________________________________________________
Phone # ___________________________________________________
Below check any current health condition that may require attention during the school day:
Allergies (be specific)
Other health conditions (be specific) ________________________
Foods _______________________ EpiPen ___ Yes ___ No
______________________________________________________
Medicines _________________________________________
Previous surgeries (be specific)_____________________________
Bee Stings
EpiPen ___ Yes ___ No
______________________________________________________
Other _____________________________________________
Previous concussion/head injury-year _______________________
Asthma
Uses emergency inhaler ___ Yes ___ No
Hearing problems
Has hearing aids ___ Yes ___ No
Cancer
Vision problems (be specific) ______________________________
Diabetes
______________________________________________________
Seizures
Wears:
Glasses
Contacts
Heart problems (be specific) ______________________________
ADD/ADHD
______________________________________________________
Behavior/emotional problems _____________________________
Physical disability (be specific) ____________________________
______________________________________________________
______________________________________________________
No current health conditions
List all medications and dosages your child receives on a continual basis: ____________________________________________________________
________________________________________________________________________________________________________________________
plEasE complEtE part i or part ii — not Both
part i — to grant consEnt
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 the designated physician or dentist, or in the event the designated practitioner is not available, by another licensed physician or dentist;
and (2) the transfer of the child to the designated hospital or any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
Date _______________________________
Parent or Guardian Signature ________________________________________________________
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 no action or to: ____________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Date _______________________________
Parent or Guardian rEfusal Signature ______________________________________________
HEALTH FORM B - Revised LLS 8/09
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Parent category: Medical