Greenfield Exempted Village School District
EMERGENCY MEDICAL AUTHORIZATION

Student Name  _________________________________________________________________________

Telephone  ____________________________________________________________________________

Address  ______________________________________________________________________________

School Attended _______________________________________________________  Grade ___________

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.

PART I OR II MUST BE COMPLETED

PART I TO GRANT CONSENT

In the event reasonable attempts to contact me

_______________________________   at  ___________________________________  ________________________  or
   Name of Parent or Guardian                              Home or Place of Employment                           Phone Number

_______________________________   at  ___________________________________  ________________________
   Circle:  Parent - Guardian - Relative                  Home or Place of Employment                           Phone Number

have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment deemed necessary by

Dr. _______________________________________  at   ________________________________ or
        Preferred Physician                                                               Phone Number

Dr. _______________________________________  at   ________________________________ or
        Preferred Dentist                                                                    Phone Number

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

Dr. _______________________________________  at   ________________________________ or any hospital reasonably accessible.  Preferred Hospital                                                   Phone Number

This authorization does not cover major surgery unless 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:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

In the event of a slight temperature or headache, ( I give ___ )  /  ( I do not give ___ ) permission to administer Tylenol or Children's Tylenol. (Check one)

Date  ___________________  Signature of Parent or Guardian  ____________________________________________

Other:  ______________________________________________   ________________  __________________________
(Please Circle)  Grandparent  -  Relative  -  Babysitter  -  Neighbor            Phone                           Address

DO NOT COMPLETE PART II IF YOU COMPLETED PART I

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 emergency treatment, I wish the school authorities to take no action or to:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Date  _________________________________________________________________________

Signature of Parent or Guardian  ____________________________________________________

Address  ______________________________________________________________________

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