Authorization To School Emergency
Medical Treatment For Minor

I, ___________, of _______ (address), am the ________ (father/mother/legal guardian) of _________, a minor, of __________ (address), who attends ______________ (name of school), located at _____________ (address).

In the event all reasonable attempts by authorized school personnel to contact me at ________ (phone number) or to contact _______ (other parent/guardian) at _______ (phone number) have been unsuccessful, I give my consent for:

1. The administration of any treatment deemed necessary by _________ (preferred physician) or ________ (preferred dentist), or, in the event the appropriate preferred practitioner is not available, by another licensed physician or dentist; and

2. The transfer of the minor to ________ (preferred hospital) or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

The following information is needed by any hospital or practitioner not having access to the minor's medical history:

Allergies: _________________________________________

Medication being taken: ____________________________

Date of last tetanus shot: ___________________________

Physical impairments: _______________________________

Other pertinent facts to which physician should be alerted:

___________________________________________________

______________________________
(Signature)

__________________________
(Date)