EMERGENCY MEDICAL AUTHORIZATION FORM

Celina City Schools, 585 E. Livingston St., Celina Oh 45822 Ph. 419/586/8300

Part I or II Must Be Completed

PART I – TO GRANT CONSENT

                STUDENT DATA

                Student Name ______________________________________   School Building ________________________

                Home Address ______________________________________  Telephone Number ______________________

                Mother ____________________________________________   Employers Daytime Phone ________________

                Father _____________________________________________   Employers Daytime Phone ________________

                Other Name ________________________________________     Employers Daytime Phone ________________

                Name of relative or childcare provider ___________________         Daytime Phone _________________________

                Address _____________________________ Phone _______________ Relationship ____________________

                MEDICAL CONSENT

                I hereby give consent for the following medical care providers and local hospital to be called f
                or my child should you feel the situation warrants such action.

                Doctor _____________________________________ Phone ___________________________________

                Dentist _____________________________________  Phone ___________________________________

                Medical Specialist _____________________________   Phone ___________________________________

                Local Hospital ________________________________    Phone ___________________________________

Listed below are facts concerning my child’s medical history, including allergies, medications being taken, and any other physical impairments or chronic conditions to which a physician should be alerted. __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

  In the event the designated practitioner is not available, I hereby give my consent for: (1) the administration of any treatment deemed necessary by another licensed physician, dentist, or medical specialist: and (2) the transfer of the child to the preferred hospital or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians, dentist, or medical specialists, concurring in the necessity for such surgery, are obtained prior to the performances of such surgery.

This information will be shared with school staff only as needed to meet the needs of the student while in school.

I GIVE MY CONSENT

Date ________________                Signature _______________________Address _______________________

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 treatment, I wish the school authorities to take the following action:

                Date ________________  Signature ________________________ Address ____________________________