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Microsoft word - emergencymedicalform
St. Joseph Consolidated School
Emergency Medical Authorization Form 2013-2014
Purpose- To enable parents to authorize emergency treatment for children who become ill or injured
while under school authority when parents cannot be reached. One form for each student must be
filled out. Please complete BOTH sides
Student Name: _______________________________Parent Name:_______________________
Home Phone: _______________ Work Phone: _______________ Cell Phone: ______________
Part I or Part II MUST be completed
Part I (To Grant Request)
Physician Name: ____________________________ Phone _________________ Dentist Name ______________________________ Phone __________________ Medical Specialist ___________________________ Phone __________________ Local Hospital Emergency Room _______________________________________
In the event reasonable attempts to contact me have not been successful. I hereby give my consent for (1) the administration of any treatment deemed necessary by the above named physician or dentist or in
the event designated the preferred practitioner is not available, by another licensed physician or dentist;
and the transfer of the child to any hospital reasonably accessible.
The 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.
List any facts concerning the child’s medical history, including allergies, medications being taken, and any
physical impairments to which a physician should be noted on the reverse side of this form.
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 medical treatment, I wish the school authorities to take no action or to:
Side 1 of 2
St. Joseph Consolidated School
Medical Information Form 2013-2014
Child's Name _____________________________________ Grade _____________
Please list any and all prescription medication(including dosage) your child is
currently taking: _______________________________________________________________________
A. Environmental or Animal
List any medicines taken (prescription or over the counter)
B. Food Allergies (please circle any that apply)
C. Medicine Allergies (please circle any that apply)
D. Latex or Medical Tapes (please circle) E. Bee stings or other insect bites (please circle)
Medical Conditions (Please circle those that apply)
Please take some moments and list any other medical conditions that may be of
concern for the safety of your child.
Side 2 of 2
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