Minford Middle School Minford Local School District  Emergency Medical  Authorization Form

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 ________________________