Challenger Learning Center of Lake Erie West Emergency Medical Form

Student Name	

Address

Home Phone	

City, State, Zip	

Date of Birth 	                   Sex 	                   Camp Year 	

Residential Parent or Guardian: Child lives with (check one):	□Both parents	□Father	□Mother	□Guardian

Father’s Name:	                   Daytime Phone:	

Father employer 	

Mother’s Name:	                   Daytime Phone:	

Mother's employer 	

Guardian's Name:	                   Daytime Phone:	

Guardian's employer 	

Name of Relative (in case above cannot be reached):

Name:	

Address:	

Name:	

Address:	

Doctor:	

Dentist:	

Medical Specialist:	

Hospital:	

Relationship:	

Phone:	

Relationship:	

Phone:	

Phone:	

Phone:	

Phone:	

Phone:	

The purpose of the following form is to enable parents and guardians to authorize the provision of emergency treatment for children who became ill or injured while under school authority, when parents or guardians cannot be reached.

Part I or II must be completed Part I – To Grant Consent
I hereby give my consent, in the event 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 may not be available, by another licensed doctor or dentists; and (2) the transfer of the child to my preferred hospital or any hospital reasonable 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 the physician and staff should be alerted:

Allergies: 	 Diabetic? □Yes	□No

Signature of Parent/Guardian	Date

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Part II – Refusal of Consent (Do not complete this portion if Part I was completed)
I do not give my consent for emergency medical treatment of my child. In event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

Signature of Parent/Guardian	Date