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OLENTANGY LOCAL SCHOOLS EMERGENCY MEDICAL AUTHORIZATION PLEASE PRINT STUDENT S FIRST NAME MIDDLE INITIAL LAST NAME HOME PHONE NUMBER GRADE ADDRESS CITY ZIP The purpose of this form is 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 or guardians cannot be reached. EMERGENCY CONTACTS HOME PHONE CELL PHONE WORK PHONE RESIDENTIAL PARENT OR GUARDIAN FIRST AND LAST NAME OTHER PARENT GUARDIAN OR RELATIVE S FIRST NAME AND LAST NAME RELATIONSHIP IF PARENT OR GUARDIAN CANNOT BE REACHED EMERGENCY CONTACT FIRST AND LAST NAME PART I OR PART II MUST BE COMPLETED PART I TO GRANT CONSENT I hereby give consent for the following medical care providers and local hospitals to be called PHYSICIAN OFFICE PHONE DENTIST MEDICAL SPECIALIST LOCAL HOSPITAL EMERGENCY ROOM PHONE 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 another licensed physician or dentist and 2 the transfer of the child to a hospital reasonably 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 a physician should be alerted are listed as follows DATE SIGNATURE OF PARENT/GUARDIAN PART II REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency medical treatment I wish the school authorities to take the following action 6/2008. 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 a physician should be alerted are listed as follows DATE SIGNATURE OF PARENT/GUARDIAN PART II REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. Facts concerning the child s medical history including allergies medications being taken and any physical impairments to which a physician should be alerted are listed as follows DATE SIGNATURE OF PARENT/GUARDIAN PART II REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency medical treatment I wish the school authorities to take the following action 6/2008. 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 a physician should be alerted are listed as follows DATE SIGNATURE OF PARENT/GUARDIAN PART II REFUSAL TO CONSENT I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency medical treatment I wish the school authorities to take the following action 6/2008.