• 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.

  • 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:

  • 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:

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  • 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:

  • Should be Empty:
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