BISHOP O'DOWD HIGH SCHOOL INTERNATIONAL STUDENT ...

Last Name:____________________
Bishop O'Dowd High School Emergency Health Information
Please Print
Student Name___________________________________ Birth Date__________________
Grade________________________
Home Address_________________________________________ City_______________ Zip________ Phone (___)_____________
Alternate Address_______________________________________ City ______________ Zip ________ Phone (___)_____________
Day
Cell
Name of Father/Guardian________________________________ Phone (____)______________Phone(____)_________________
Day
Cell
Name of Mother/Guardian _______________________________ Phone (____)______________ Phone (___)__________________
Relative, Friend or Neighbor Name __________________ Relationship _______________ Phone (____)________________
Authorized to act on their behalf
if parent/guardian cannot be reached Name __________________ Relationship _______________ Phone (____)________________
CONSENT FOR EMERGENCY TREATMENT
(I, We), the undersigned parent or legal guardian of ____________________________________ a minor, do hereby authorize a representative of Bishop O’Dowd
High School as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care that is
deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provision of the California
Medical Practice Act, on the medical staff of an accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said
hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and
power on the part of the above mentioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care that the designated physician
in the exercise of his/her office or best judgment may deem advisable. This authorization shall remain effective throughout our son/daughter’s four years at Bishop
O’Dowd and your yearly consent on the emergency treatment update which is completed at re-registration will serve as validation of this signature, unless sooner
revoked in writing and delivered to the designated agent(s). I understand that the school does not assume any responsibility for payment to physician in any case.
However, in an emergency, the school may choose a physician. I also authorize the release of my son/daughter to drive home after an emergency situation or to be driven
home by an authorized person when the situation has been deemed safe by administrator’s in charge at Bishop O’Dowd.
Mother’s Signature & Date: _____________________________________
Father’s Signature & Date: ______________________________________
Legal Guardian Signature & Date: ___________________________________________
PLEASE FILL OUT BOTH SIDES