Medical Emergency Form - St. Joseph Consolidated School

St. Joseph Consolidated SchoolEmergency Medical Authorization Form 2013-2014Purpose- To enable parents to authorize emergency treatment for children who become ill or injuredwhile under school authority when parents cannot be reached. One form for each student must befilled out. Please complete BOTH sidesStudent Name: _______________________________Parent Name:_______________________Address: ______________________________________________________________________Home Phone: _______________ Work Phone: _______________ Cell Phone: ______________Part I or Part II MUST be completedPart I (To Grant Request)Physician Name: ____________________________ Phone _________________Dentist Name ______________________________ Phone __________________Medical Specialist ___________________________ Phone __________________Local Hospital Emergency Room _______________________________________In the event reasonable attempts to contact me have not been successful. I hereby give my consent for(1) the administration of any treatment deemed necessary by the above named physician or dentist or inthe event designated the preferred practitioner is not available, by another licensed physician or dentist;and the transfer of the child to any hospital reasonably accessible.The authorization does not cover major surgery unless the medical opinions of two other licensedphysicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performanceof such surgery.List any facts concerning the child’s medical history, including allergies, medications being taken, and anyphysical impairments to which a physician should be noted on the reverse side of this form.___Parent SignatureDatePart II Refusal to ConsentI do NOT give my consent for emergency medical treatment of my child. In the event of illness or injuryrequiring medical treatment, I wish the school authorities to take no action or to:____________________Parent SignatureDateSide 1 of 2

St. Joseph Consolidated SchoolMedical Information Form 2013-2014Child's Name _____________________________________ Grade _____________I. MEDICATIONSPlease list any and all prescription medication(including dosage) your child iscurrently taking:_______________________________________________________________________II.ALLERGIESA. Environmental or AnimalList any medicines taken (prescription or over the counter)_______________________________________B. Food Allergies (please circle any that apply)1. Peanuts or othernuts2. Milk Allergy orLactose Intolerant3. Red dye or otherfood dyes4. Citrus FruitsC. Medicine Allergies (please circle any that apply)1. Amoxicillin2. Augmentin3. Bactrim4. Ceclor5. Codeine6. Erythromycin7. Pediazole8. Penicillin9. Sulfa Drugs10. Suprax11. Others _______________D. Latex or Medical Tapes (please circle)E. Bee stings or other insect bites (please circle)III.Medical Conditions (Please circle those that apply)A. Asthma (inhalerYes or No)B. Broken bones inlast 12 months______________C. Contacts orglassesD. DiabetesE. EczemaF. HereditarySpherocyotisG. Kidney orBladderproblemsH. Migraines(List any medsgiven__________)I. Motions SicknessJ. NissonFunderpectionK. Orthodonticappliances(Please list_____________)L. Tubes in Ears (If inlast year pleaselist date_______Please take some moments and list any other medical conditions that may be ofconcern for the safety of your child.______________________________________________________________________________________________________________________________________________________Side 2 of 2