Emergency Medical Authorization Form

ADVERTISEMENT

EMERGENCY MEDICAL AUTHORIZATION FORM
William V. Fisher Catholic High School
Student Name: ____________________________________
Birth Date: _______________ Grade: ______
Address: ______________________________________ City/Zip Code: ____________________________
Home Phone #: _______________ Mom’s Cell # ________________ Dad’s Cell #_________________
Student lives with: ___Both Parents ___Mother ___Father ___Guardian ___Step-Parent
Parents are: ____Married ___Divorced ___Separated ___Widowed
Is there a court custody order pertaining to this child? _________ Who has custody? _________
*A copy of custody papers is REQUIRED to be on file*
PARENT/GUARDIAN(S) AND EMERGENCY CONTACTS
Call
Name:
Relationship:
Day Phone:
Cell Phone:
Order:
____
_____________________________________
______________________
__________________
________________
____
_____________________________________
______________________
__________________
________________
____
_____________________________________
______________________
__________________
________________
____
_____________________________________
______________________
__________________
________________
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
PART I: TO GRANT CONSENT
I hereby give consent for the following medical care providers and local hospital to be called:
Physician: _____________________________________
Phone _____________________
Dentist: _______________________________________
Phone _____________________
Medical Specialist: ______________________________
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 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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go