Name ___________________________
Clark/Peebles
Senior Project
2007-2008
Westlake City School District
EMERGENCY MEDICAL FORM
Student Name: FORMTEXT Date of Birth: Phone: ( ) -
School: Grade: Homeroom Teacher:
Address: Home E-Mail Address:
Purpose: To enable parents to authorize emergency treatment for children who become ill or injured while under school authorization, when parents cannot be contacted.
PART I (TO GRANT CONSENT)
In the event reasonable attempts to contact me at: (Please add AREA CODES)
|
Print Full Name: |
Home Phone |
Work Phone |
Cell Phone |
I. Mother: |
( FORMTEXT ) - |
( ) - |
( ) - |
|
Father: |
( ) - |
( ) - |
( ) - |
|
Other Responsible
Person: |
( ) - |
( ) - |
( ) - |
have been unsuccessful, I hereby give my consent for:
(1) the administration of any treatment deemed necessary by Dr. FORMTEXT (preferred physician) Phone ( FORMTEXT ) FORMTEXT - FORMTEXT
or Dr. (preferred dentist) Phone ( ) - 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 FORMTEXT (preferred hospital) (St. John’s West Shore, Fairview General, or Lakewood). If the emergency is such that your child needs immediate attention, he/she will be taken to the most accessible of these hospitals.
This authorization doeas not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurrint in the necessity of the surgery, are obtained before the surgery is performed.
Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted are:
FORMTEXT
Date: FORMTEXT Signature of Parent:
Address:
PART II (REFUSAL TO CONSENT)
I DO NOT consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to:
Date: Signature of Parent:
Address: