EMERGENCY MEDICAL AUTHORIZATION FORM 2020-2021
PURPOSE: To enable parents or guardians to AUTHORIZE emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached. Upon completion, parents will submit the form electronically. The form will be used to identify the medical options of the undersigned parent.
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Email *
Child Name Last, First, Middle *
Prefers to be called:
Pronouns:
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Student's Address, Street, PO Box/Apt#, City and Zip Code *
Student's Birth Date *
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Student's Cell Phone Number *
Parent/Guardian First and Last Name *
Daytime Telephone # *
Parent/Guardian First and Last Name *
Daytime Telephone # *
Guardian/Child Care Provider First and Last Name *
Daytime Telephone # *
ALTERNATE EMERGENCY CONTACTS (Local people to contact if parent/guardian cannot be reached)
ALTERNATE EMERGENCY CONTACTS #1  - PLEASE INCLUDE BOTH NAME AND TELEPHONE NUMBER                                     *
ALTERNATE EMERGENCY CONTACTS #1  - RELATIONSHIP TO STUDENT *
ALTERNATE EMERGENCY CONTACTS #2  - PLEASE INCLUDE BOTH NAME AND TELEPHONE NUMBER                                     *
ALTERNATE EMERGENCY CONTACTS #2  - RELATIONSHIP TO STUDENT *
INSURANCE INFORMATION
Student's Insurance (primary) *
Subscriber Name *
ID Number *
TO GRANT CONSENT
in case of an emergency involving my child and I cannot be reached, I hereby give consent to transport my child to the following medical care providers and hospital, and authorize these providers and hospital to give any reasonable and customary medical and health care deemed necessary.
Doctor/ Nurse Practioner/Physician Assistant           Name and Telephone Number *
DENTAL EXAMINATION PRIOR TO ENROLLMENT
Please note: in the 2021-2022 school year schools are required to verify evidence of student dental examination prior to enrollment, or parents must sign a waiver indicating they understand the risks associated with opting not to have their student receive a dental examination.
Dentist and Telephone Number *
Date of Last Dental Examination
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If your want this to serve as a waiver of dental service for your child sign your first and last name and the date below.
Name of Hospital *
If, for any reason. the above listed medical care providers or hospital cannot be reached, I authorize appropriate transport and medical care of my child to any appropriate medical care provider, hospital or medical facility. This authorization does not cover major surgery unless one other doctor/dentist concur to the need. Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply with this section. It is understood that I will be financially responsible for all emergency care.
Signature of Parent/Guardian *
Date *
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FACTS CONCERNING THE CHILD'S MEDICAL HISTORY TO WHICH A PHYSICIAN SHOULD BE ALERTED
Please indicate if student has had or is currently under treatment for any condition.
If your child  has any of the preceding conditions, please list the name of the conditions and give the year or age when problem occurred.
If it applies, list anything your child is allergic to:
If it applies, list the medicines or injections your child is allergic to:
If it applies, tell us the date(s) and reason(s) your child was hospitalized for any serious illness, surgery or accident.
Use of contact lenses? *
Use of glasses? *
Medications taken at home?
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If yes, what and when?
Medications taken at school?
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If yes, name of the medication and when the medication needs to be taken?
Have you ever been informed of the need to be on antibiotic therapy prior to dental treatment?
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If yes, identify required therapy?
Please add any conditions not listed.
A copy of your responses will be emailed to the address you provided.
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