Boardman Local Schools
EMERGENCY MEDICAL AUTHORIZATION
Grade / Section / Homeroom: _______________ School: _______________

Student Name _____________________________________  Home Phone Number ________________________
                                           Last               First              M.I.

Address ____________________________________________________________________________________
Street Number                                       City                               State                       Zip

Mothers Name: ________________________________ Fathers Name: ________________________________

Mothers Work Phone: ____________________________ Fathers Work Phone: ___________________________

Mothers Cell Phone: _____________________________ Mothers Work Phone: __________________________

Student Social Security # __________________________ Parent email address ___________________________

Purpose:  To enable parents / guardians to authorize the provision of emergency treatment for children who become ill or injured under school authority, when parents or guardians cannot be reached. In the event that reasonable attempts have been unsuccessful to contact a parent at the above numbers you have my permission to contact anyone listed below. Please list names and phone numbers of contacts in the order they are to be called in case of an emergency.

____________________________ First Contact	____________________ Relationship to Child	____________________ Work / Daytime Phone	____________________ Alternate or Cell Phone
____________________________ Second Contact	____________________ Relationship to Child	____________________ Work / Daytime Phone	____________________ Alternate or Cell Phone
____________________________ Third Contact	____________________ Relationship to Child	____________________ Work / Daytime Phone	____________________ Alternate or Cell Phone

IMPORTANT NOTICE
1. List at least 2 contact persons (other than parents)
2. PLEASE update information – changes in name, address, phone number, etc.
3. List medical conditions – allergies, asthma, diabetes, epilepsy, etc.
4. List medications. Include inhalers, pills and liquids

The STATE OF OHIO requires the Medical Emergency Authorization form to completed and on file in the school ANNUALLY. This enables you to assist your child during times of illness and/ or injury. Thank you!

Name / Address / Phone / of Child Care Provider / (Latch Key Program):

___________________________________________________________________________________________
Name                                                  Address                                                                  Daytime Phone

PART I or II MUST BE COMPLETED

Part I:  To Grant Consent

I hereby give my consent for the administration of any treatment deemed necessary by the preferred physician, dentist, specialist and / or hospital listed below:  OR in the event the designated preferred practitioner or hospital is not available, by another licensed physician or dentist or any hospital reasonably accessible.  This authorization does not cover major surgery unless the medical opinions of the two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

Physician ______________________________________________	Phone (      ) _____________________
Dentist ________________________________________________	Phone (      ) _____________________
Medical Specialist _______________________________________	Phone (      ) _____________________
Local Hospital __________________________________________	Phone (      ) _____________________
Facts concerning the child’s history including allergies, medications being taken, and any physical impairments such as heart conditions, diabetes, epilepsy, etc., to which a physician and school staff should be alerted. _________________________________________________________________________________________ __________________________________________________________________________________________ Signature of Parent / Guardian Giving CONSENT                                                                              Date

Page 1 of 2

Part II:  Refusal to Consent (DO NOT complete if Part I above is completed)

I DO NOT give my consent for emergency medical treatment of my child.  In the event of illness or injury requiring emergency treatment, I wish the school authorities to take NO ACTION or the following action:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

__________________________________________________________________________________________
Signature of Parent / Guardian Giving NO CONSENT                                                                   Date

* Medical History / Allergies / Medications

Medical History _______________________________________________________________________________

Allergies ______________________________________  Medications ___________________________________