Fillable Emergency Medical Authorization Form - 2016-2017 printable pdf download

File: EBBA-E/JO-E

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT

EMERGENCY MEDICAL AUTHORIZATION FORM (2016-2017)

(Ohio Revised Code 3313-712)

STUDENT’S NAME

STUDENT ID#:

GRADE:

___________________________________________

________________

_________

STREET ADDRESS

___________________________________________

DATE OF

________________

BIRTH:

CITY, STATE, ZIP

___________________________________________

PARENT EMAIL:

___________________________________________

PURPOSE: To enable parents and guardians to authorize the provisions of emergency treatment or transportation for children who become ill or injured while under school

authority, or during an emergency situation, when parents cannot be reached. IF ANY CHANGES OCCUR, NOTIFY THE SCHOOL IMMEDIATELY. (Please PRINT or TYPE,

and SIGN the FORM IN THE APPROPRIATE AREAS.)

PARENT/LEGAL GUARDIAN:

Student lives with: (please check) and enter information below:

Father & Mother

 Mother only

 Father only

 Shared Parenting

 Foster Parent

 Other _________________

NAME

CELL PHONE

HOME PHONE

WORK PHONE

RELATIONSHIP

List three (3) names of people to be contacted in the EVENT OF AN EMERGENCY:

I understand that my child may be released to anyone on the list if ill, injured, or if an emergency occurs, and he/she must leave school.

NAME

CELL PHONE

HOME PHONE

WORK PHONE

RELATIONSHIP

___________________________________________________

Please provide detailed information regarding any medical problems, allergies, special needs:

__________________________________________________________________________________________________________________

___________________________________________________________________________________________

Medication your child takes daily:

For educational purposes, special medical problems, physical impairments or other facts concerning your child’s medical history may be shared with teachers or other support staff involved in the

academic setting. If you DO NOT CONSENT for the sharing of this information, you are required to state this in writing and submit your statement with this form to your school administrator.

PART I OR PART II MUST BE COMPLETED-

(complete ONE SECTION ONLY)

PART I: TO GRANT CONSENT

PART II: REFUSAL TO GRANT CONSENT

(A) I hereby GIVE MY CONSENT for the following medical care providers and local

I DO NOT GIVE MY CONSENT for emergency medical treatment for my

hospital to be called:

child. In the event of illness or injury requiring emergency treatment, I

DOCTOR: _____________________________

Phone: ______________

DENTIST: _____________________________

Phone: ______________

wish the school authorities to take the following action:

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 above-named doctor,

_____________________________________________________________

or in the event the designated preferred practitioner 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.

_____________________________________________________________

(B) I authorize Milford Exempted Village School District to release any information which I have

_____________________________________________________________

provided this school district concerning any medical history, including information regarding

allergies, medications, physical condition, etc. of the student named above to any employee of

_____________________________________________________________

the school district and/or volunteer providing medical service to the school district who has

responsibility for such student while the student is at school, participating in a school sponsored

function, or is being transported by the school.

SIGNATURE OF PARENT/LEGAL GUARDIAN/

DATE

SIGNATURE OF PARENT/LEGAL GUARDIAN/

DATE

or STUDENT (IF 18 YEARS OR OLDER)

Emergency Medical Authorization Form - 2016-2017

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