Emergency Medical Authorization

EMERGENCY MEDICAL AUTHORIZATION

Student Name ______

TRI – VALLEY LOCAL SCHOOLSAddress ______

______

PURPOSE: To enable parents to authorize emergency

Treatment for children who become ill or injured while Telephone ______

Under school authority when parents cannot be reached. School Name ______

Grade ______Birthdate ______

Mother’s Name ______Cell Phone: ______

Place of Work ______Work Phone: ______

Father’s Name ______Cell Phone: ______

Place of Work ______Work Phone: ______

List 3 other emergency phone numbers. Please identify the person listed ( i.e. grandparent, aunt, neighbor, friend, childcare provider etc.)

Name ______Phone ______Relationship ______

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted

Allergies: ______Date of last tetanus shot: ______

Medications being taken: ______Physical Impairments: ______

(heart problems, epilepsy, etc)

Other pertinent facts to which a physician should be alerted: ______

Date: ______SIGNATURE OF PARENT OR GUARDIAN ______

______

PART 1: TO GRANT CONSENT

I hereby give consent for the following medica care providers and local hospital to be called:

PHYSICIAN ______PHONE ______

DENTIST ______PHONE ______

MEDICAL SPECIALIST ______PHONE ______

LOCAL HOSPITAL ______E. R. 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 above-neamed doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; 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.

______

DATESIGNATURE OF PARENT / GUARDIAN

Do not complete part 2 if you completed part 1

PART 2: REFUSAL TO GRANT CONSENT

I do NOT give my consent for emergency 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: ______SIGNATURE OF PARENT / GUARDIAN______