Emergency Medical Authorization

Emergency Medical Authorization
Purpose: For parents/guardians to authorize emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached.
For
Name of Athlete
Address
City, State, Zip
Phone
Format: (000) 000-0000.
Name of School: Heritage Christian School
Parent/Legal Guardian
Work Telephone
Format: (000) 000-0000.
In the event reasonable attempts to contact me, the parent/guardian are unsuccessful, I, the undersigned parent/legal guardian do authorize any hospital, clinic, or licensed physician to treat my/our child and administer any x-ray examination, anesthetic, or surgical diagnosis rendered under the general or special supervision of any member of the medical staff of the hospital, clinic, or office.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Our preferred physician is
Phone
Format: (000) 000-0000.
Our preferred dentist is
Phone
Format: (000) 000-0000.
Our preferred hospital is
In the event the designated preferred practitioner is not available, we authorize in advance another licensed physician or dentist the authority and power to render care in his/her best judgment and the transfer of the child to any hospital reasonably accessible. It is also understood that every effort shall be made to contact the parent/legal guardian prior to rendering treatment to the patient, but that treatment will not be withheld if the parent/guardian cannot be contacted. Permission is also granted for the school's athletic director or coach to provide emergency treatment to my/our child prior to his/her admission to any medical facility.
Signature of ParentLegal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
List of restrictions/physical impairments
List of special medication taken by my child
Should be Empty: