EMERGENCY MEDICAL
WEST CLERMONT
SCHOOL DISTRICT
AUTHORIZATION FORM
Purpose:
Enables parents and guardians to authorize the provision of emergency treatment for children who
become ill or injured while under school authority, when parents/guardians cannot be reached.
This Emergency Medical Authorization, required by O.R.C. 3313.712, must be on file for each student
PLEASE PRINT AND RETURN TO SCHOOL WITHIN 7 DAYS.
Your Email Address ___________________________
Please Print
Student’s Name _______________________________ School _________________________ Grade ___________
Student’s Address _________________________________________________________________________________
Date of Birth ____________________________ Student ID ______________________ Teacher _________________
Note: Listing individuals below allows your student to be released to those individuals (must be age 18 or over).
Parent/Guardian’s Name ____________________________________
Relation to Student _____________________
Home Phone _________________________
Cell ______________________ Work _________________________
Parent/Guardian’s Name ____________________________________
Relation to Student _____________________
Home Phone _________________________
Cell ______________________ Work _________________________
List in order person(s) who may be notified and to whom your child may be released if the school cannot reach you:
Name
Relationship
Home Phone
Cell Phone
Work Phone
______________________
________________
________________
________________
_____________
______________________
________________
________________
________________
_____________
______________________
________________
________________
________________
_____________
Facts concerning the child’s medical history including allergies, medications and any physical impairment to which a
physician should be alerted ___________________________________________________________________________
Doctor to be called ___________________________________________ Phone _________________________________
Dentist to be called __________________________________________ Phone _________________________________
Preferred Local Hospital ______________________________________________________________________________
Part 1 – 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 above named doctor or, in the event the designated
preferrred hospital 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.
Date _________________________
Signature of parent/guardian _________________________________________
Part 2 – 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 _________________________________________
SF01 – 7/13