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EMERGENCY MEDICAL AUTHORIZATION

Please print
Student's name Student's address

Birth date

Mother' s/guardian's name

Home phone Father/guardian' s name Home phone

Work phone Work phone

Cell phone Cell phone

lf

above parentVguardians cannot be reached, please call: Work phone

Contact's name
Home phone

Relationship ,, Cellphone

In case of accident or serious illness, I request the parish to contact me or my designate. If this cannot be done, I authorize the parish to call the physician or dentist listed on this form and to follow hiVher instructions. If the physician or dentist named cannot be reached, the parish may seek medical services that seem necessary. I realize the parish does not assume responsibility for the payment of medical
expenses.
S i gnature

of parenVguardian

Date

I
S

In the event emergency treatment is needed, I give the hospital, its authorized personnel and/or physician permission to treat my son/daughter as necessary. ignature of parenVguardian Date

Allergic reactions (medications, food, insects, etc.)

Medication(s) currently being taken and reason

My child has special medical/mental conditions

I yes I

No (if yes, please describe)

Physician/clinic Dentist Hospital preference

lnsurance company

Phone Phone

Policy number

OR

I do not give my consent for emergency medical treafinent of my child. In the event of illness or injury requiring medical treatment I with the parish authorities to take no action or to:

grrature of parent/guardian

Date