Greeneview Schools
EMERGENCY MEDICAL AUTHORIZATION AND INFORMATION
Please PRINT, SIGN & RETURN TO SCHOOL THREE (3)COPIES
Click in box to type information.
School: Student Name: Grade: DOB:
Address: P. O. Box:
City: State: Zip: Home Phone:
Mother's Name: Daytime Phone:
Father's Name: Daytime Phone:
Custodial Parent/Guardian: Daytime Phone:
Emergency Calling Order
Please list below four names (including yourself-parents) which you would prefer for us to call in case of an emergency. Please put this list in the order of whom you want called first, second, etc. Please list First and Last name, Phone # and Relationship to Student.
1.
2.
3.
4.

COMPLETE PART I or PART II

Part I: TO GRANT CONSENT
I hereby give consent for the folloing medical care providers and local hospital be called:

Physician: Phone: Dentist:
Phone:
Medical Specialist: Phone: Local Hospital: Phone:
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 above-named doctors, 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 any hospital reasonably accessible. This authroization 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 being taken, and any physical impairments to which a physician should be alerted:
Date: Signature of Parent/Guardian:__________________________________
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, please take the following actions:
Date: Signature of Parent/Guardian:__________________________________