Unity East                             Emergency Medical                                                                                            Authorization 2023-2024
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 and guardians cannot be reached in a timely manner.  Every effort will be made to provide medical services as needed and as designated below.

List parent(s) first and then list family or friends.  You may NOT exclude a parent if there is joint custody of the child unless you show court documentation of sole custody belonging to either parent.  

If any of the fields do not apply to you, put NA.
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Email *
Students Name (Last, First) *
Grade *
Street Address *
City *
Mother's name (Last, First) *
Mother's main phone number *
Mother's secondary phone number  
Father's name (Last, First) *
Father's main phone number *
Father's secondary phone number
Emergency contact #1 name and relation to student. *
Emergency contact #1 main phone number *
Emergency contact #1 secondary phone number
Emergency contact #2 name and relation to student. *
Emergency contact #2 main phone number *
Emergency contact #2 secondary phone number
Emergency contact #3 name and relation to student *
Emergency contact #3 main phone number *
Emergency contact #3 secondary phone number
If unable to reach me at any of the above telephone numbers, I hereby give my consent for necessary treatment by Dr. ______________ *
(S)He is our preferred physician.  If not available, I give consent for necessary treatment by another licensed physician.  I prefer treatment at _________ hospital.   *
Electronic Signature - Type Full Name *
This Electronic Signature Verification Statement is intended to document a physical copy of my signature.  This Emergency Medical Authorization shall continue in full force and in effect until CUSD #7 is advised in writing of any changes desired by the undersigned.  I understand that any expenses incurred as a result of transportation and treatment will be my financial responsibility.  
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