Student Emergency Medical Form

Danville  Local  Schools  

Student  Emergency  Medical  Form  

Please  complete  entire  form.  

 

Student  Name  ______________________________________________________________________  

Date  of  Birth  _________________  Grade  __________  Home  Phone  #  _________________________  

Address  ___________________________________________________________________________    

Please  indicate  if  NEW  address_____  

 

The  purpose  of  this  form  is  to  enable  parents/guardians  to  authorize  the  provision  of  emergency  treatment  for  their  children  who  become  

ill  or  injured  while  under  school  authority  when  parents/guardians  cannot  be  reached.  

CURRENT  RESIDENTIAL  PARENT/GUARDIAN:  

Mother  ________________________________  Cell  #  ________________  Work  #  _______________  

Father  _________________________________  Cell  #  ________________  Work  #  _______________  

Guardian  _______________________________  Cell  #  ________________  Work  #  ______________  

OTHER  RELATIVE/CHILD  CARE  PROVIDER/EMERGENCY  CONTACTS:

 

Name  _____________________________________________  Relationship  _____________________  

Address  ___________________________________________________________________________  

Home  Phone  #  ___________________  Cell  #  ___________________  Work  #____________________  

 

Name  _____________________________________________  Relationship  _____________________  

Address  ___________________________________________________________________________  

Home  Phone  #  ____________________  Cell  #  ___________________  Work  #___________________

 

 

PART  I    TO  GRANT  CONSENT  

Doctor  _______________________________________________  Phone  #  ______________________  

Dentist  _______________________________________________  Phone  #  ______________________  

Medical  Specialist  ______________________________________  Phone  #  ______________________  

Knox  Community  Hospital  (740-­393-­9000)  OR  Other  _______________________________________  

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  my  child  to  the  nearest  hospital.    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  surgery.  

 including  allergies,  asthma,  diabetes,  

medications   being   taken,   and   any   medical/physical   need   to   which   the   school/coach   and   a   physician  

should  be  alerted  _____________________________________________________________________              

___________________________________________________________________________________  

_______________________________________________  Date  of  last  Tetanus  ___________________    

FIELD  TRIP  PERMISSION  FORM  

 

 

 

 

 

 

SCHOOL  YEAR  ___________________      

I   hereby   consent   to   allow   my   son/daughter   _________________________   to   participate   in   any   field  

trip  or  school-­related  activity  during  the  present  school  year.    It  is  understood  that  this  initial  permission  

slip  will  serve  throughout  the  present  school  year.  

Parent/Guardian  Signature  ____________________________________________  Date  ____________  

 

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  authorize  the  school  to  take  the  following  actions:  

___________________________________________________________________________________

___________________________________________________________________________________          

Parent/Guardian  Signature  _____________________________________________  Date  ___________