Athletic Emergency Medical Authorization Form
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1
2Athletic
EMERGENCY MEDICAL AUTHORIZATION (per H.B. 639) File: Policy EMR Form
GRADE
Liberty Union-Thurston Schools
(Student’s Name)
1108 South Main Street
(Date of Birth)
Baltimore, Ohio 43105
Purpose: To enable parent(s)/guardian(s)
(Complete Home Address / including PO Box #)
to authorize the provision of emergency
treatment for children who become ill or
(
)
(
)
2014-2015
injured while under school authority, when
st
nd
(1
Choice Phone)
(2
Choice Phone)
(School Year)
parent(s)/guardian(s) cannot be reached.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PART I - TO GRANT CONSENT
Residential / Custodial Parent(s)/Guardian(s):
Mother
Daytime Phone (
)
Father
Daytime Phone (
)
Other Name
Daytime Phone (
)
Name of relative or childcare provider
Address
Phone
Relationship
IF MY CHILD REQUIRES MEDICAL ATTENTION DUE TO ILLNESS OR INJURY, AND IN THE EVENT REASONABLE
ATTEMPTS TO CONTACT ME HAVE BEEN UNSUCCESSFUL, I HEREBY GIVE CONSENT FOR MY CHILD TO BE TREATED BY
THE FOLLOWING MEDICAL PROVIDERS, AND TO BE TRANSPORTED TO THE FOLLOWING HOSPITAL. IF THESE
MEDICAL PROVIDERS ARE NOT AVAILABLE, I GIVE MY CONSENT FOR MY CHILD TO BE TREATED BY ANOTHER
LICENSED PHYSICIAN OR DENTIST, AND TO BE TRANSPORTED TO ANY HOSPITAL REASONABLY ACCESSIBLE.
Medical Insurance Coverage/Policy Number
Doctor
Phone (
)
Dentist
Phone (
)
Medical Specialist
Phone (
)
Local Hospital
Phone (
)
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.
FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS BEING TAKEN, AND ANY
PHYSICAL IMPAIRMENTS TO WHICH A PHYSICIAN SHOULD BE ALERTED
(In order to better protect the health of your child, this information will be provided to school employees teaching, working with, or supervising your child.
This information will be treated in a confidential manner.)
(Date)
(Legible Signature of Parent(s)/Guardian(s)
(Address)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PART II - REFUSAL TO CONSENT
I DO NOT GIVE MY 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 NO ACTION OR TO:
(Date)
(Legible Signature of Parent(s)/Guardian(s)
(Address)
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