EMERGENCY MEDICAL FORM 2023-2024

Student Name:	Home No.	Cell No.	

Address:	City:	State:	Zip:	

Date of Birth:	Sex:	

Living with (check one)	                    Both parents	                  Mother only	                  Father only

	Other (please explain)	

Father’s Name	Mother’s Name:	

Guardian Name (if different from above):	

Number of children in family under school age	 (please list children of school age below)

Name:	Grade:	Name:	Grade:

If parents cannot be reached in case of illness or accident call: (PLEASE PRINT CLEARLY)

Name:	

Relationship to you:	

Name:	

Relationship to you:	

Phone No:	

Phone No:	

Father’s place of employment:	Work No.	

Mother’s place of employment:	Work No.	

Preferred Doctor:	Phone No.	

Preferred Dentist:	Phone No.	

Preferred Hospital:	Phone No.	

Pertinent facts concerning your child’s medical history to which the school or a doctor should be alerted: Allergies? (If none, state No)	Diabetic?Yes	                  No
Other:	

Medication(s) (name and dosage):	

Diagnoses:	

Emergency Medical Authorization

The purpose of the following form is to enable parent/guardian(s) to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents and/or guardians cannot be reached (either Part 1 or Part II must be completed)
PART I

I hereby give my consent, in the event of reasonable attempts to contact either parent or guardian have been unsuccessful, for (1) the administration of any treatment deemed necessary by my preferred doctor or dentist, or in the event the designated preferred doctor or dentist is not available, by another licensed doctor or dentist, and 92) the transfer of the child to my preferred hospital or any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed doctors or dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

Date:	                  Parent/Guardian(s) Signature:	

PART II

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 NO ACTION, or:

Date:	                  Parent/Guardian(s) Signature: