St. Joseph Consolidated School Emergency Medical Authorization Form 2013-2014
Purpose- To enable parents to authorize emergency treatment for children who become ill or injured while under school authority when parents cannot be reached. One form for each student must be filled out. Please complete BOTH sides
Student Name: _______________________________Parent Name:_______________________ Address: ______________________________________________________________________ Home Phone: _______________ Work Phone: _______________ Cell Phone: ______________ Part I or Part II MUST be completed Part I (To Grant Request)
Physician Name: ____________________________ Phone _________________ Dentist Name ______________________________ Phone __________________ Medical Specialist ___________________________ Phone __________________ Local Hospital Emergency Room _______________________________________
In the event reasonable attempts to contact me have not been successful. I hereby give my consent for (1) the administration of any treatment deemed necessary by the above named physician or dentist or in
the event designated the preferred practitioner is not available, by another licensed physician or dentist;
and the transfer of the child to any hospital reasonably accessible.
The 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.
List any facts concerning the child’s medical history, including allergies, medications being taken, and any
physical impairments to which a physician should be noted on the reverse side of this form.
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 medical treatment, I wish the school authorities to take no action or to:
Side 1 of 2 St. Joseph Consolidated School Medical Information Form 2013-2014
Child's Name _____________________________________ Grade _____________
MEDICATIONS Please list any and all prescription medication(including dosage) your child is
currently taking: _______________________________________________________________________
ALLERGIES A. Environmental or Animal
List any medicines taken (prescription or over the counter)
B. Food Allergies (please circle any that apply)
C. Medicine Allergies (please circle any that apply)
D. Latex or Medical Tapes (please circle) E. Bee stings or other insect bites (please circle)
Medical Conditions (Please circle those that apply) Please take some moments and list any other medical conditions that may be of concern for the safety of your child.
Side 2 of 2
¿INFORMAR PARA QUÉ? Nunca antes, como en nuestra época, la información ha adquirido un valor comercial tan exorbitante. Parece que cual una horda de zombis, los seres humanos hemos entrado en una vorágine informativa. Más aún con las nuevas tecnologías como herramientas que han adquirido un valor fundamental en las prácticas cotidianas. Internet, por ejemplo, se ha convertido en u