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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(419)  935-4744

FAX (419) 933-6000

25 W Perry St, Willard, OH 44890, USA

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