Emergency Medical Authorization Form

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OLENTANGY LOCAL SCHOOLS
EMERGENCY MEDICAL AUTHORIZATION FORM
Student Name:
__________________________________
Birth Date:
_______________
Grade:
______
Address:
__________________________________
Student lives with:
________________________________
City/Zip Code:
__________________________________
Home Phone Number:
________________________________
PARENT/GUARDIAN(S) AND EMERGENCY CONTACTS
Can
Call
Pick
Order:
Relationship:
Name:
Day Phone:
Home Phone:
Cell Phone:
Up:
____ ___________ _______________________
____________
____________ ____________ ___
____ ___________ _______________________
____________
____________ ____________ ___
____ ___________ _______________________
____________
____________ ____________ ___
____ ___________ _______________________
____________
____________ ____________ ___
____ ___________ _______________________
____________
____________ ____________ ___
Please indicate if your child has any of the following:
 
1) Allergies (please list):
_____________________________________________________________________________________________________
2) Medications* (please list):
_____________________________________________________________________________________________________
3) Inhalers* (please list):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4) Other medical concerns or
conditions to which medical
_____________________________________________________________________________________________________
personnel should be alerted?
_____________________________________________________________________________________________________
* Use and/or possession of any medications, whether prescribed or not, requires the appropriate documentation to be completed and on file with the school.
PART I OR PART II MUST BE COMPLETED
I hereby give consent for the following medical care providers and local hospital to be called:
PART I: TO GRANT CONSENT
Office Phone:
Address (Preschool only):
_______________________
________________
______________________________
Physician:
_______________________
________________
______________________________
Dentist:
_______________________
________________
Medical Specialist:
_______________________
________________
Local Hospital:
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 appropriate medical professional; 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.
_________________________________________________________________
_______________________
Signature of Parent/Guardian for Grant to Consent
Date
PART II: REFUSAL TO CONSENT
I do NOT give 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:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________
_______________________
Signature of Parent/Guardian for Refusal to Consent
Date

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