Emergency Medical Authorization Form
ADVERTISEMENT
1EMERGENCY MEDICAL AUTHORIZATION FORM
(Required per HB 639)
Student Name _____________________________________________________________ School __________________________
Address____________________________________________________________________________________________________
Street/P.O. Box
City
Zip
Home Phone (
) ____________________ DOB ____ /____/____ Grade ________ Teacher/Team________________________
PARENT CONTACT INFORMATION
MOTHER/GUARDIAN:
FATHER/GUARDIAN:
Name______________________________________________
Name_________________________________________________
Address_______________________________________
Address__________________________________________
City/State/Zip___________________________________
City/State/Zip_____________________________________
Email address __________________________________
Email address ______________________________________
Home PH: _______________ Cell PH:_______________
Home PH: ________________ Cell PH:_________________
Work Place: ______________WK PH:_______________
Work Place: _______________ WK PH:_________________
Is there a legal custody order that applies to this child? Yes_____ No_______ Copy of custody papers must be on file in office.
If yes, please explain: ________________________________________________________________________________
PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school
authority. In the event that you can not be reached, please list (3) people to whom you give permission to pick up your child from school in case of illness or
injury. If we are unable to reach you, we will contact the people listed below in the order they are listed.
Name
Home #
Cell #
Work #
Relationship to Child
(
) ______________ (
) _____________ (
) ______________ ______________
1._________________________
_________________
(
) ______________ (
) _____________ (
) ______________ ______________
2.
_
(
) ______________ (
) _____________ (
) ______________ ______________
3._________________________
Facts concerning the child’s medical history including allergies, medications being taken or current health concerns:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
May this health information be shared with appropriate school personnel such as your child’s teacher(s)?
Yes_______
No________
Date___________ Signature of Parent/Guardian
___________________________________
COMPLETE EITHER PART I OR PART II
___________________________________
PART I – CONSENT FOR TREATMENT
PART II – REFUSAL TO GRANT
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my
CONSENT FOR TREATMENT
consent for (1) the administration of any treatment deemed necessary by the named doctor,
I do NOT give my consent for emergency medical
or in the event the designated practitioner is unavailable, by another licensed physician or
treatment of my child. In the event of illness or
dentist; and (2) the transfer of the child to any hospital reasonably accessible. This
injury requiring treatment, I wish the school
authorization does not cover major surgery unless the medical opinions of two other licensed
authorities to take the following action:
physicians or dentists, concurring in the necessity for such surgery, are obtained to the
___________________________________________
performance of such surgery.
I hereby give consent for the following medical care providers and local hospitals to be called:
___________________________________________
Doctor ________________________________ Phone (
) ________________
___________________________________________
Dentist _______________________________ Phone (
) _________________
Hospital ___________________________________________________________
Date__________________
Date____________________
___________________________________________
Signature of Parent/Guardian
________________________________________
Sign only if refusal to consent
Signature of Parent/Guardian
12/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business