NORDONIA HILLS CITY SCHOOLS

EMERGENCY MEDICAL AUTHORIZATION FORM

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Student Name. . . . . . . . . . . . . . . . . . . . . .School Attending

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Street Address City Zip Code Telephone

RESIDENTIAL PARENT OR GUARDIAN

Mother________________ Daytime Phone___-___________Father__________________ Daytime Phone____-____________

Other Name________________________ Daytime Phone____-_______________

IF PARENT OR GUARDIAN IS UNAVAILABLE, NAME OF RELATIVE OR DESIGNATED CHILDCARE PROVIDER TO CONTACT:

_________________________________________________________ _______________________________________________

Name Street Address

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Relationship Phone

***************MEDICAL ALERT INFORMATION***************

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician or the school should be alerted include:

_____________________________________________________________________________________________________________________________________________________________

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CONSENT

Please complete either Part I or Part II below.

Part I is completed to grant consent for emergency treatment. Part II is completed to refuse consent.

Part I: TO GRANT CONSENT
A. I hereby give consent for the following medical care providers and local hospitals to be called:

Doctor_____________________________ Phone _____-________________ Dentist _________________________ Phone ______-________________

Medical Specialist ____________________Phone _____-________________ Local Hospital _________________________ 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 doctor, 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 reasonable 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.

Signature of Parent/Guardian _______________________________________________ Phone ____________________________

Address ______________________________________________________________ City ________________________________ Date ____________

B .Sagamore Hills Medical Center is our nearest emergency room, and therefore, most emergencies would be transported to their facility. It is always possible after emergency treatment to make arrangements to transport your child to your own preferred hospital.

I hereby give my consent for emergency treatment of my child at Sagamore Hills Medical Center .

Signature of Parent/Guardian_______________________________________________ Phone ______________________________ Date____________

Part II: REFUSAL OF 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 actions:

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Signature of Parent/Guardian _______________________________________________ Phone ____________________________

Address __________________________________________________ City ____________________________________________ Date ___________________