Emergency Medical Authorization Form printable pdf download

Student Name _________________________________________________________________________

(Please print)

Last

First

Grade/Teacher

Fairport Harbor Exempted Village School District

EMERGENCY MEDICAL AUTHORIZATION FORM

(Ohio Revised Code 3313.712)

Date of Birth ____________________________

Home Phone ________________________________

School _________________________________

Address ____________________________________

School Year _____________________________

City _______________________ ZIP ____________

Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured

while under school authority, when parents or guardians cannot be reached. This information will be shared, as necessary, with

teachers, administrative staff, school nurse, and other school personnel.

Parent/Guardian Information

Mother’s Name _______________________ Daytime Phone ______________________ Cell Phone __________________________

Father’s Name ________________________ Daytime Phone ______________________ Cell Phone __________________________

Other

1. _________________________ Daytime Phone ______________________ Cell Phone __________________________

Emergency

Contacts 2. _________________________ Daytime Phone ______________________ Cell Phone __________________________

3._________________________ Daytime Phone ______________________ Cell Phone __________________________

It is extremely important that you provide ANY pertinent medical history or information about existing conditions that may affect

your child at school.

Medical Information:

____________________________________________________________________________________________________________

Medications:

____________________________________________________________________________________________________________

Allergies:

____________________________________________________________________________________________________________

PART 1 OR PART 2 MUST BE COMPLETED

PART 1: TO GRANT CONSENT

PART 2: REFUSAL TO CONSENT

I hereby give consent for the following medical care

I do NOT give my consent for emergency medical

providers and local hospital to be called:

treatment of my child. In the event of illness or injury

requiring emergency treatment, I wish the school

Doctor_______________________ Phone _____________

authorities to take the following action:

Dentist_______________________ Phone_____________

_______________________________________________

Local Hospital/Emergency Room____________________

_______________________________________________

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 designed 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.

_______________________________________________

Signature of Parent/Guardian

Date

Signature of Parent/Guardian

Date

Emergency Medical Authorization Form

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