Emergency Medical Authorization Form
ADVERTISEMENT
1
2EMERGENCY MEDICAL AUTHORIZATION FORM
PURPOSE: To enable parents or guardians to AUTHORIZE emergency treatment for children who become ill or
injured while under school authority, when parents cannot be reached. Upon completion, parents must return
this form to the school. The original form and any copies thereof may be used to identify the medical options of
the undersigned parent.
__________________________
________________________
___________________
________
School District
School Building
Home Room Teacher
Grade
Student’s Full Name _____________________________________________________________________________
Last
First
Middle
Social Security #
Student’s Address _______________________________________________________________________________
Street/Road
P.O. Box/Apt #
City
Zip Code
Student’s Birth Date ___________________________________ Telephone (
) _____________________________
Mother’s Full Name ___________________________________ Daytime Phone (
) _________________________
Father’s Full Name ____________________________________ Daytime Phone (
) _________________________
Guardian or Child Care Provider ____________________________Daytime Phone (
) _______________________
Guardian or Child Care Provider’s Address ___________________________________________________________
Street/Road
P.O. Box/Apt #
City
Zip
ALTERNATE EMERGENCY CONTACTS (Local people to contact if parents cannot be reached)
1. Name______________________ Phone_____________2. Name_____________________ Phone _____________
INSURANCE INFORMATION
Student’s Insurance
Subscriber’s Name
_________________
____________________
____________
ID Number
(primary)
TO GRANT CONSENT
In case of an emergency involving my child and I cannot be reached, I hereby give consent to transport my child
to the following medical care providers and hospital, and authorize these providers and hospital to give any
reasonable and customary medical and health care deemed necessary:
Doctor __________________________________________________________ Phone (
) ___________________
Dentist __________________________________________________________ Phone (
) ___________________
Nurse Practitioner/Physician Assistant __________________________________Phone (
) ___________________
Hospital _________________________________________________________ Phone (
) ___________________
If, for any reason, the above listed medical care providers or hospital cannot be reached, I authorize appropriate
transport and medical care of my child to any appropriate medical care provider, hospital or medical facility. This
authorization does not cover major surgery unless one other doctor/dentist concur to the need.
Nothing in this section shall be construed to impose liability on any school official or school employee who, in
good faith, attempts to comply with this section. It is understood that I will be financially responsible for all
emergency care.
Signature of Parent/Guardian _______________________________________ Date _________________________
-Complete Form on Other Side-
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business