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Emergency Medical Authorization

(REQUIRED PER HB 639)
  • Please enter a value between 7 and 12.
  • Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority. By listing the people below, you are giving permission for them to pick up your child from school. In an emergency situation, parents/relatives would be contacted in the order listed below.
  • NameHome Phone Cell PhoneWork PhoneRelationship To Student  
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  • I hereby give consent for the following medical care providers and local hospital to be called:
  • DoctorPhone  
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  • DentistPhone  
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  • Medical Specialist Phone  
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  • Local Hospital Phone  
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  • 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 reasonable accessible. This authorization does not cover major surgery unless the medical options or two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

    I also give permission to the school nurse or designee to administer the following non-prescription medications to my child: Tums, cough drops as needed.
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  • 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:
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