Purpose - To enable parents and guardians to authorize emergency treatment for student who becomes ill or injured while under school activity, when parents or guardians cannot be reached

School: ___________________________________________________________

Student Name: ______________________________________________________________________________

Grade: _______________________

Address: ____________________________________________________________________________________

Phone # (Home): __________________________________ (Work) ________________________________________

Mothers Name: _________________________________________________ Daytime phone: _________________________________________

Father’s Name: _________________________________________________ Day time Phone: ________________________________________

Guardian’s Name: ______________________________________________ Day Time Phone: ________________________________________

Medical Specialist: _____________________________________________ Day Time Phone: _______________________________________

Name of relative or child care provider: ________________________________________________

Relationship: ________________________________________________________________

Address: ______________________________________________________________________

Day Time Phone: _________________________________________________________

PART I OR II MUST BE COMPLETED

Part I – TO GRANT CONSENT

Thereby give consent for the following medical care providers and local hospitals to be called:

Doctor: ______________________________________________________________
Day Time Phone: _________________________________________________________

Dentist: _____________________________________________________________
Day Time Phone: _________________________________________________________

Medical Specialist: ____________________________________________________
Day Time Phone: _________________________________________________________

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) any treatment deemed necessary by above named physician or dentist. In the event the designated preferred practitioner is not available, by another licensed physician or dentist: and (2) the transfer of student to the nearest available hospital. 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.

PLEASE CHECK ALL THAT APPLY TO YOUR CHILD:

_______ On Medication / If so, what? _________________________ Does the medication need to be administered during school?
              If so, When? __________________________________________
_______ Diabetes
_______ Asthma / (Medication Taken____________________________________________________)
_______ Epilepsy
_______ Heart Condition
_______ Allergies
_______ Physical limitations (please explain): __________________________________________________________________
             _________________________________________________________________________________________________
_______ Vision loss
_______ Other

DATE: _____________________________
Required: (Signature of Parent/Guardian) _______________________________________________________________________

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 treatment. I wish the school authorities to take the following action ___________________________________________________________.

DATE: _____________________________
Required: (Signature of Parent/Guardian) _________________________________________________________________________