• PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for students who become ill or injured while under school authority, when parents or guardians cannot be reached.

  • Either Part I or Part II Must Be Completed

  • Part I: - To Grant Consent

    In the event of an emergency, contact:
  • If unsuccessful, I hereby give my consent for administration of any treatment deemed necessary by:

  • In the event that the designated preferred practitioner or preferred dentist is not available, I give my consent for treatment by another licensed physician or dentist, and the transfer of my child to the designated hospital, or any hospital reasonably accessible.

    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.

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  • Part II: Refusal To Consent

    This part is only to be completed if you did not complete Part I.
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  • Emergency Medical Authorization

    A school shall have provided to the parent or legal guardian of every student enrolled in school an emergency medical authorization form. Thereafter, the school shall, within thirty (30) days after the entry of any student into a school, provide the parent or legal guardian of such student, either as part of any registration form, or as a separate form, a copy of the Emergency Medical Form.

    When the form is returned to the school, the school shall keep the form on file, and shall send the form to any school of a city, exempted village, local, or joint vocational school district to which the student is transferred. Upon request of his parent or guardian, authorities of the school in which the student is enrolled may permit such parent or guardian to make changes in a previously filed form, or to file a new form.

    If a parent or guardian does not wish to give such written permission, he shall indicate in the proper place on the form the procedure he wishes school authorities to follow in the event of a medical emergency involving his child.

    Even if a parent or guardian gives written consent for emergency medical treatment, when a student become ill or is injured and requires emergency medical treatment while under school authority, or while engaged in an extracurricular activity authorized by the appropriate school authorities, the authorities of the school in which the student is enrolled shall make reasonable attempts to contact the parent or legal guardian before the treatment is given. The school shall present the student’s emergency medical authorization form or copy thereof to the hospital or practitioner rendering treatment. (cf. Rev. Code 3313-712)

PLEASE USE THE ST. PETER CHURCH ADDRESS FOR ALL MAIL