MISD Medical Treatment of a Student 2

WELLNESS AND HEALTH SERVICES MEDICAL TREATMENT
AUTHORIZATION TO SECURE EMERGENCY MEDICAL TREATMENT OF A STUDENT
Student's Name: *

First Name Last Name
Student ID# *
Grade Level
Date of birth: *

Month Day Year
Name of Parent/Guardian *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Work Phone *
Cell Phone *
Local person to contact if parent or guardian cannot be reached:
Emergency Contact *

First Name Last Name
Phone Number *
Relationship to the student: *
Medical Conditions:
Medications or drugs to which the student has had an allergic or adverse reaction: *
Type NONE if no allergic reactions
Does this student have an Individual Health Plan or an Emergency Action Plan on file with school nurse?

YES NO
Does this student have a form on file with the nurse allowing them to self carry an inhaler or EPI-PEN?

YES NO
IF STUDENT TAKES MEDICATIONS, PLEASE COMPLETE MEDICATION PERMISSION FORM ON BAND WEBSITE AND SUBMIT TO MISD PERSONNEL.

IF YES TO ANY OF THE ABOVE QUESTIONS, NOTIFY SCHOOL NURSE ONE WEEK PRIOR TO SCHOOL TRIP.
Student's Physician or other preferred health-care provider
Physician Phone Number
Student's Dentist
Dentist Phone Number
Part 1:
I hereby authorize the Superintendent of Midland Independent School District or a designated representative to secure any and all emergency medical care and treatment for {studentName} for acute illness suffered, injury sustained, or other situation requiring emergency medical treatment while at school or participating in school-related activities.

I understand that cost of services provided by ambulance, private physician, clinic, hospital, or dentist remains the responsibility of the parent or guardian and will not be assumed by the District or any of its officers or employees.
Insurance Coverage: *

I do have medical insurance coverage for my child: I DO NOT have medical insurance coverage for my child.
Attach photocopy of Front & Back of Insurance Card (if applicable)

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Upload Student's Physical & Medical History Form

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All Students must complete page 1 of the form. Incoming 9th graders and new Band Members must also have a physical by their physician and submit the signed form. Cancel of
Click here for the Physical & Medical History Form
Signature of parent or guardian: *

Clear
Date *

Month Day Year
Date
I understand that the District will attempt to contact me as soon as possible if such action is necessary.
Signature of parent or guardian: *

Clear
Date *

Month Day Year
Date
Copies of this authorization may be presented to the admissions office of a hospital or clinic or to a physician or dentist. Other distribution may occur only within the limitations of the Family Educational Rights and Privacy Act.
Should be Empty:

Medical Conditions:

Part 1: