Residential Parent or Guardian
Mother’s Name: _____________________________ Daytime Phone: __________________________
Father’s Name: _____________________________ Daytime Phone: __________________________
Other Name: ______________________________ Daytime Phone: ___________________________
Name of Relative or Childcare Provider
Name: ____________________________________ Relationship: ____________________________
Address: __________________________________ Daytime Phone: ___________________________
City / State / Zip : _____________________________________________________________________
School Name: _______________________________________________________________________
Student Name:________________________________________________________________________
Address: _________________________________ City / State / Zip:_____________________________
Phone: __________________________________
Emergency Medical Authorization Form: to enable parents / guardians to
authorize the provision of emergency treatment for children who become ill or injured
while under school authority, when parents or guardians cannot be reached.
Please complete both sides of the Emergency Medical Authorization Form!
Please Print
PART 2: Emergency Medical Authorization
Form
TO GRANT CONSENT: I hereby give consent for the following medical care providers and local hospital
to be called:
Physician : ____________________________________ Phone: ______________________________
Dentist : ____________________________________ Phone: ______________________________
Medical Specialist : _____________________________ Phone: ______________________________
Local Hospital : _________________________________ Emergency Room #: ___________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for
(1) the administration of any treatment deemed necessary by above-named doctors, or, in the event the
designated preferred practitioner is not available, by