Dayton Christian School System Emergency Medical Authorization Form printable pdf download

Dayton Christian School System

Emergency Medical Authorization Form

NAME OF CHILD ____________________________________________________________________Birthdate________________________

Homeroom/Devotional Teacher _____________________________________________Grade ____________

School Year 20____20____

Home Address ________________________________________________________________ School District _________________________

City_________________________________Zip____________________Home Phone _________________ Student’s Cell_______________

Student lives with___________________________________________________________________________________________________

PARENT’S OR LEGAL GUARDIAN’S NAMES AND PHONE NUMBERS

Name _______________________Relationship_________ Cell:_____________ Work/Home ____________Email______________________

Are there any custody issues with this student? ___Yes ___ No If yes, please explain____________________________________________

Names and grades of siblings__________________________________________________________________________________________

Permission for older siblings to transport younger siblings ___Yes ___No

AUTHORIZED PERSONS to assume responsibility for school dismissal and provision of care when parent or guardian listed above cannot be

reached. Students will only be released to parent or guardian or those authorized by parent or guardian.

1._____________________________________ Relationship_________________ _Cell: _______________Work/Home________________

2._____________________________________ Relationship_________________ _Cell: _______________Work/Home________________

3._____________________________________ Relationship_________________ _Cell: _______________Work/Home________________

4._____________________________________ Relationship_________________ _Cell: _______________Work/Home________________

MEDICAL INFORMATION The following medical information may be shared with your student’s teachers, secretary, counselor, principal,

physical education teacher, cafeteria staff, athletic director, coach and all clinic staff unless otherwise instructed.

____Asthma

____ Seizures ____ Diabetes ____Severe Allergy to _____________________________________ Epipen ____Yes____No

Other_____________________________________________________________________________________________________________

Physical impairments________________________________________________________________________________________________

Medications currently taking __________________________________________________________________________________________

Do any of the above medical conditions require medication at school? ___Yes___No

(See clinic staff if child has allergies, diabetes, asthma, seizures, health concerns or medications to complete appropriate medical forms.)

Family Physician or Pediatrician__________________________________________________________Phone_________________________

Family Dentist________________________________________________________________________Phone ________________________

Local Hospital Preference ____________________________________________________________________________________________

Insurance which applies to child________________________________________________________________________________________

___ CONSENT FOR EMERGENCY TRANSPORTATION AND MEDICAL TREATMENT:

In the event my/our child needs to be transported by

ambulance or emergency vehicle, I/we authorize transportation. In the event reasonable attempts to contact me/us have been unsuccessful, I/we

hereby give my/our consent for administration of any treatment deemed necessary by Dr. ______________________________(preferred doctor)

or Dr_________________________ (preferred dentist); or, in the event the designated practitioner is not available, by another doctor or dentist;

and the transfer of the child to the above stated hospital or any hospital reasonably accessible. This authorization does not cover major surgery

unless the medical opinions of two (2) other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the

performance of such surgery.

___ REFUSAL OF CONSENT

. I/We do not give my/our consent for emergency medical treatment or emergency transportation of my/our child.

In the event of illness or injury requiring emergency treatment, I/we wish the school authorities to take no action or to:_______________________

SIGNATURE(S) OF PARENTS/GUARDIANS_________________________________________________ Date: _________________________

_________________________________________________Date:__________________________

Dayton Christian School System Emergency Medical Authorization Form

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