Emergency Medical Form

Download this form in Microsoft Word or Adobe Acrobat PDF format or print the form below.  Simply highlight the text below, right-click and choose print.  Choose to print Selection and it should fit on one side of paper.

DO NOT FOLD  EMERGENCY MEDICAL AUTHORIZATION

Newark Catholic High School

STUDENT______________________________________DOB_____________________________________

ADDRESS___________________________________________CITY________________________________

TELEPHONE  (res) (_____)__________________________(work) (_____)___________________________

HEALTH INSURANCE_______________________________ CODE (if needed)_______________________

            Purpose - To enable parents to authorize emergency treatment for children who become ill or

            injured while under school authority, when parents cannot be reached.

Part I or Part II MUST be completed

PART I  (to grant consent)

Facts concerning the student’s medical history including allergies, medications being taken, and any

physical impairments to which a physician should be alerted.

________________________________________________________________________________________

In the event reasonable attempts to contact me at:

(phone) ____________________________________ or (phone) ____________________________________ have been unsuccessful, I hereby give my consent for:

(1) administration of any treatment deemed necessary by:

            (Physician) Dr.__________________________________________________

            Address________________________________________________________

            Telephone_(______)______________________________________________

            (Dentist) Dr.____________________________________________________

            Address________________________________________________________

            Telephone_(______)______________________________________________

If the designated preferred practitioner is not available, another licensed physician or dentist has my permission to give treatment.

(2) and the transfer of the child to (preferred hospital_____________________________________________

                                                                                                (or 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 before the surgery is performed.

Signature of parent/guardian_______________________________________ Date_____________________

******************************************************************************************************************************

PART II (refusal to consent)

I DO NOT GIVE 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:

________________________________________________________________________________________

________________________________________________________________________________________

Signature of Parent ________________________________________  Date: __________________________