2022-2023 EMERGENCY MEDICAL AUTHORIZATION FORM

GRADE
TODAY'S DATE

MonthDayYear
Date
2022-2023 EMERGENCY MEDICAL AUTHORIZATION FORM
School
Student Name
Student Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Purpose – to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Residential parent or Guardian:
Mother's Name
Daytime Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Mother's Employer
Mothers Employer Phone Number

Area CodePhone Number
Father's Name
Daytime Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Father's Employer
Father's Employer Phone Number

Area CodePhone Number
Other's Name
Other's Phone Number

Area CodePhone Number
Name of relative or Childcare Provider:
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
YesNo
YesNo
In the Event of an emergency early dismissal my child should: (Put X in Box)
Ride the bus
Wait to be picked up
PART I OR II MUST BE COMPLETED
(See Reverse Side)
PART I: TO GRANT CONSENT (The separate authorization to Administer Medication or Carry Inhaler form must be completed if applicable

I hereby give consent for the following medical care providers and local hospital to called:
Physician
Physician Phone Number

Area CodePhone Number
Dentist
Dentist Phone Number

Area CodePhone Number
Medical Specialist
Medical Sepcialist Phone Number

Area CodePhone Number
Local Hospital
Hospital Phone Number

Area CodePhone Number
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 name doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (1) the transfer of the child to any hospital reasonable 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.
Facts concerning the child's medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted:
Date

MonthDayYear
Date
Signature

Clear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 the following action:
Date

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

2022-2023 EMERGENCY MEDICAL AUTHORIZATION FORM

PART I OR II MUST BE COMPLETED

(See Reverse Side)

PART II: REFUSAL TO CONSENT