NEWBURY STUDENT EMERGENCY MEDICAL AUTHORIZATION

Name: School Year:

Address: Student Grade:

Phone:

Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority and parents cannot be reached. The school recommends that parents have their signatures notarized.

Residential Parent or Guardian:

Mother’s Name: Daytime Phone:

Father’s Name: Daytime Phone:

Other’s Name: Daytime Phone:

Name of Relative or Childcare Provider:

Relationship:

Address: Daytime Phone:

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 hospital to be called:

Physician: Phone:

Dentist: Phone:

Specialist: Phone:

Hospital: Emergency Phone:

In the event reasonable attempts to contact me have been unsuccessful, I 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 any 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 impairment to which a physician should be alerted are as follows

:

Parent/Guardian Signature: Date:

PART II: REFUSAL TO GRANT CONSENT

I DO NOT give my consent for the emergency treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

Parent/Guardian Signature: Date: