Emergency Medical Authorization Form printable pdf download

EMERGENCY MEDICAL AUTHORIZATION FORM

School ______________________________

Student Name ___________________________________

Grade ______________________________

Address _________________________________________

Telephone _______________________________________

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.

Information provided on this form will be shared with school personnel who interact with your child to ensure

his/her safety at school unless you note otherwise.

Residential (lives with) Parent or Guardian:

(Designate – work or home)

Mother’s Name ______________________________

Daytime Phone __________________________________

Father’s Name ______________________________

Daytime Phone __________________________________

Guardian’s Name ______________________________

Daytime Phone __________________________________

Name of Relative or Childcare Provider (circle one):

________________________________________________________

Phone _______________________________

Address _________________________________________________________________________________________

PART I OR II 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 ______________________________________________________

Phone _____________________________

Dentist _____________________________________________________

Phone _____________________________

Preferred Local Hospital _____________________________________

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 the above-named doctor, or, in the event the designated practitioner

is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital 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.

IMPORTANT

Please list any facts concerning the child’s medical history including allergies, medications being taken,

current medical conditions, and any physical impairments to which the school and a physician should be

alerted.

__________________________________________________________________________________________________

_____________________________________

________________________________________________

Date

Signature of Parent/Guardian

PART II – REFUSAL TO CONSENT

I do not give 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

Emergency Medical Authorization Form

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