Emergency Medical Authorization

Student's Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/ Guardian Name (Primary)(Required)

Email(Required)

Phone Number(Required)

Parent/ Guardian Name (Secondary)

Phone Number

Emergency Medical Authorization

Purpose - to enable parents and guardians to authorize the provision of emergency for children who become ill while under school authority, when parents or guardians cannot be reached.

Participant Date of Birth(Required)

Participant Place of Birth(Required)

Please read & Confirm Below:(Required)

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 my preferred doctor or dentist, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to my preferred hospital or any hospital reasonably accessible.

Preferred Doctor(Required)

Preferred Dentist(Required)

Preferred Hospital(Required)

Student's Medical History(Required)

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 prior to the performance of such surgery. Facts concerning the child's medical history including allergies, medications taken, and any physical impairments to which a physician should be alerted:

Insurance Carrier(Required)

Policy Number(Required)

Upload a Copy of Insurance Card Here

Max. file size: 256 MB.

Parent/Guardian eSignature(Required)