Emergency Medical Authorization Form 2014-2015 printable pdf download

All policy changes for 2014-2015 are italicized

CYO Athletic Policies & Procedures 2014-2015

---EMERGENCY MEDICAL AUTHORIZATION---

Purpose: To enable parents or guardians to authorize the provision of emergency treatment for players

who become ill or injured while under coaches authority when parents or guardians cannot be reached.

THIS FORM MUST BE FILLED OUT IN INK EACH SCHOOL YEAR!

Last Name ___________________________________ First Name _______________________________

Street Address ________________________________ City: ______________ State: _____ Zip: _______

Home Phone_______________________

Grade __________

Date of Birth ____________________

Parish_______________________________________

Sport ____________________________________

Mother’s Name/cell phone/email: _____________________________________________________________

Father’s Name/cell phone/email: _____________________________________________________________

Guardian’s Name/cell phone/email: ___________________________________________________________

Dependable relative or neighbor to call in an emergency (illness or injury) when parent or guardian cannot be

reached (name)

___________

(phone) _______________________________

Allergies

Date of last tetanus shot

Medication being taken

(Name)

(Dosage)

(Time(s) taken)

List of health problems. Example: asthma, vision, epilepsy, diabetes, hearing, bone or muscle problems, etc.

Medical Insurance Firm

Policy#

_____

PART I OR II MUST BE COMPLETED

Part I – TO GRANT CONSENT

If unable to reach parent or guardian, I hereby give my consent for 1) the

administration of any treatment deemed necessary by

(physician)

or _______________________________ (dentist) in the event that the designated practitioner is not available

another licensed physician or dentist and 2) the transfer of the player to

(hospital)

or any hospital reasonably accessible.

This authorization does not cover surgery unless the medical opinions of two other licensed physicians or

dentists concurring in the surgery are obtained prior to the performance of such surgery.

________________________________________________________________________________________

(Parent or guardian’s signature & date signed)

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 team authorities to take no action or to:

________________________________________________________________________________________

(Parent or guardian’s signature & date signed)

2014- 2015 CYO Policies & Procedures – page 25

Emergency Medical Authorization Form 2014-2015

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