AUSTINTOWN LOCAL SCHOOL DISTRICT
EMERGENCY MEDICAL AUTHORIZATION FORM
As Mandated by House Bill 639

For Grades 7-12.                Grade: _______________

Student Name: Date of Birth:
Address: Phone:
 
CUSTODIAL PARENT(S) OR GUARDIAN

Mother's Name: Daytime Phone:
Home Address: Employer:
Father's Name: Daytime Phone:
Home Address: Employer:
 

CONSENT FOR NURSING / HEALTHCARE

  Yes - I consent to the expanded school health services provided by the Fitch School based Health Center. I understand that I will be contacted with the results of examinations and treatment plans.

  No - Please limit the nursing care provided for my child to traditional school nurse duties.

Generic Tylenol Consent
Purpose - To enable parents and guardians to authorize the provision or emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

  Yes - I give my permission for generic Tylenol to be given to my child.

  No - I do not give permission for generic Tylenol to be given to my child.

PART I --- To Grant Consent
I do hereby give consent for the following medical care providers and local hospital to be called:

Doctor: Phone:
Dentist: Phone:
Medical Specialist: Phone:
Local Hospital: Phone:
Emergency Room: Phone:
 
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration or any treatment deemed necessary by above doctor, or in the event to designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concurring in the necessity of such surgery, are obtained prior to the performance of such surgery.
 
Date:  _____________________          Signature:____________________________________________
 

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 the following action:

Notes:

 
 
Date:  _____________________          Signature:____________________________________________
 
Parent or Guardian:  In the event that the clinic staff needs to contact me during school hours, I can be contacted at the following numbers: (H) Home, (W) Work, (C) Cell, (P) Pager. Please list all phone numbers with the Area Code first!
 
1st Choice:

Name:

Relationship:

 Number with area code:
H:
W:
C:
P:
2nd Choice:

Name:

Relationship:

 Number with area code:
H:
W:
C:
P:
3rd Choice:

Name:

Relationship:

 Number with area code:
H:
W:
C:
P:
 
Alternate Contacts:  In the event you are unable to reach me at the above numbers you have my permission to contact the following alternates. They have my permission to receive health care information regarding my child and can take them home during school hours if needed. (H) Home, (W) Work, (C) Cell, (P) Pager. Please list all phone numbers with the Area Code first!
 
1st Choice:

Name:

Relationship:

 Number with area code:
H:
W:
C:
P:
2nd Choice:

Name:

Relationship:

 Number with area code:
H:
W:
C:
P:
 
HEALTH CARE PROVIDER INFORMATION
 
Preferred Physician:

Name:

Number with area code:

 
Preferred Dentist:

Name:

Number with area code:

 
Health Insurance
Plan / Company:

Name:

Plan Number:

Number with area code:
 

Please list facts concerning the child's medical history including allergies, Medications being taken, and any physical impairments to which a physician should be alerted:

 

 

Circle Whichever Applies to your Child:  Diabetes   -  Asthma  -  Bee Sting  -  Peanut Allergy  -  Heart Condition  -  ADD  -  Other: __________________.

May the school nurse share this information with teacher:
________ Yes
________ No
 
Please notify the clinic staff immediately if phone number (s) change at any time during the school year.

Date:  _____________________          Signature:____________________________________________