ST FRANCIS XAVIER SCHOOL
EMERGENCY MEDICAL FORM
St. Francis Xavier School
Emergency Medical Authorization Form
Student’s Name _____________________________ Grade ____ Date of Birth ________
Address _________________________________________________________________
Street _________________________ City ________________ State ____________
Home Phone # ________________________
Parent/Custodial Guardian __________________________________________________
Father’s Name ________________________________
Father’s Home Address _____________________________________________________
Street _________________________ City ________________ State ____________
Father’s Daytime Phone # ________________________ Cell # _____________________
Father’s Place of Employment ________________________________________________
Mother’s Name ________________________________
Mother’s Home Address ____________________________________________________
Street _________________________ City ________________ State ____________
Mother’s Daytime Phone # ________________________ Cell # _____________________
Mother’s Place of Employment _______________________________________________
Please list three additional people we might contact if unable to reach parent/guardian.
1. Name ________________________________
Relationship __________________________ Daytime phone __________________
2. Name ________________________________
Relationship __________________________ Daytime phone __________________
3. Name ________________________________
Relationship __________________________ Daytime phone __________________
Note: It is the responsibility of the parents and guardians to notify the school if changes to this form are to be made.
Part I or II MUST BE COMPLETED
(See reverse side)
Part I: TO GRANT CONSENT
I hereby give consent for the following medical care providers and local hospital to be called:
Physician ____________________________________ Phone # __________________
Address _______________________________________________________________
Dentist ______________________________________ Phone # __________________
Address _______________________________________________________________
Medical Specialist _____________________________ Phone # _________________
_
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.
2. The transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
PLEASE LIST ANY FACTS CONCERNING CHILD’S MEDICAL HISTORY. Including allergies, medications being taken, and physical impairments to which a physician should be alerted: ____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Date ______________ Signature of Parent/Guardian ___________________________
Part II: REFUSAL TO GIVE EMERGENCY MEDICAL 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 the following actions: ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Date _____________ Signature of Parent/Guardian ______________________________
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