Emergency Medical Form

Emergency Medical Authorization Revised 5/6/2020 This form meets the requirement for Ohio Revised Code Section 3313.712. Programs may use this form or build their own.

Name of School/Grade Entering

Student Name

Phone

Address

Mother's Name

Daytime Phone

Father's Name

Daytime Phone

Other's Name

Daytime Phone

Name of Relative or Childcare Provider

Relationship

Daytime Phone

Address

Emergency Contact¹ #1

Daytime Phone

Address

Emergency Contact #2

Daytime Phone

Address

Emergency Contact #3

Daytime Phone

Address

1 Emergency contact information is required in accordance with Ohio Administrative Code Rule 3301-37-08 (for preschool programs) and Ruila 2301 27 in

PART I OR II MUST BE COMPLETED:

PART I - TO GRANT CONSENT I hereby give consent for the following medical care providers and local hospital to be called:

Doctor

Phone

Dentist

Phone

Medical specialist

Phone

Local Hospital

Emergency Room Phone

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

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-named doctor, 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. Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted:

Signature of Parent/Guardian

Clear

Address

Date

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 (written instructions must be completed)

Signature of Parent/Guardian

Clear

Date

Address

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: