EMERGENCY MEDICAL AUTHORIZATION & FIELD TRIP CONSENT

Student Name School Building

Student Address Primary Emergency Contact Telephone Number

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

Residential Parent/Guardian

Mother’s Name Daytime Phone

Evening Phone Cellular Phone
Father’s Name Daytime Phone
Evening Phone Cellular Phone
Other’s Name Daytime Phone
Evening Phone Cellular Phone
Name of Relative or Childcare Provider
Address
Relationship Daytime Phone
Evening Phone Cellular Phone

PART I OR II MUST BE COMPLETED AND RETURNED TO THE SCHOOL OF ATTENDANCE

PART I - TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospital to be called:
Physician Phone
Dentist Phone
Medical Specialist Phone
Local Hospital ER 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 physician/dentist, or, in the event the
designated preferred practitioner is not available, by another licensed physician/dentist; and (2) the transfer of
the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two (2) other licensed
physicians/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:

(OVER)
I authorize the above named student to go on school-sponsored field trips during the current school year. I
understand that this includes all school-sponsored field trips both on foot and also by bus.

It is understood and agreed that the Oberlin City Schools and the teacher/administrator/coach in charge shall
exercise reasonable care and precautions to make these trips as safe as possible. Responsibility beyond this
cannot be assumed by the employee or the school.

Specific information regarding field trips will be sent home prior to the individual field trip.

EMERGENCY MEDICAL AUTHORIZATION & FIELD TRIP APPROVAL

Date Signature of Parent/Guardian

DO NOT COMPLETE PART II (BELOW) IF PART I (ABOVE) COMPLETED

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, I wish the school authorities to take the following action:

Date Signature of Parent/Guardian

R.C. 3313.712

PART III – SUPPLEMENTAL INFORMATION (OPTIONAL)

Student’s Birthdate Grade Teacher/Homeroom

Date of Last Tetanus

Student resides with (circle all that apply) Mother Father Step-Parent Guardian Other

Additional Contact Information for those who have authority to make decisions in an emergency situation
involving this student.

Step-parent Home # Work # Mobile #

Guardian Home # Work # Mobile #

Alternate Home # Work # Mobile #

(relative/child care provider)

Green
Revised 09/2016