Academics.......Activities.......Athletics.......Clubs.......Community.......Welcome
Minford Middle School
Minford Local School District
Emergency Medical
Authorization Form
Falcan1.gif (6137 bytes)

School __________________  Grade __________ Student's Name _______________________________

Street Address ___________________________ City, State & Zip _______________________________

Telephone Number (with area code) _________________________ Birth date ______________________

Purpose - - To enable parents and guardians to authorize the provision of emergency treatment for children who
become ill or injured while under school authority, when parents or guardians cannot be reached.

Residential Parent or Guardian

Mother's First & Last Name _____________________________________________________________

Mother's Daytime Phone (with area code)____________________________________________________

Father's First & Last Name ______________________________________________________________

Father's Daytime Phone (with area code) ____________________________________________________

Other Contact Person's First & Last Name __________________________________________________

Other Contact Person's Daytime Phone (with area code) ________________________________________

Name of Relative or Childcare Provider

_____________________________________________ Relationship to Child ______________________

Street Address _________________________________ City, State & Zip _________________________

Daytime Phone Number (with area code) ____________________________________________________



Page 2:  To Grant Consent

I hereby give consent for the following medical care providers and local hospital to be called:

Physician _______________________________________Phone Number (with area code) ____________

Dentist _________________________________________Phone Number (with area code) ____________

Medical Specialist ________________________________ Phone Number (with area code) ____________

Local Hospital ___________________________________ Emergency Room 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 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
impairments to which a physician should be alerted:

Date _______________ Signature of Parent or Guardian _______________________________________

Street Address_________________________________ City, State and Zip ________________________

Our thanks to the Minford High School Web class for this page!
Falcan1.gif (6137 bytes)