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Latchkey Emergency Medical Authorization 2022

This Emergency Medical Authorization, required by O.R.C. 3313.712, must be on file for each student. 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/guardians cannot be reached.

Student First Name*

Answer Required

Student Last Name*

Answer Required

Student Grade*

Answer Required

Address

Street Address

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City

Answer Required

Zip/Postal

Answer Required

Date of Birth*

Answer Required

Homeroom*

Answer Required

Guardian 1 Name and Relationship*

Answer Required

Guardian 1 Phone Numbers*

For example, Home: 513-555-1234, Cell: 513-555-9876, Work: 513-555-3456

Answer Required

Guardian 2 Name and Relationship

Answer Required

Guardian 2 Phone Numbers

For example, Home: 513-555-1234, Cell: 513-555-9876, Work: 513-555-3456

Answer Required

List in order person(s) who may be notified and to whom your child may be released if the school cannot reach you:

Emergency Contact #1 and Relationship to Child*

Answer Required

Emergency Contact #1 Phone Numbers*

For example, Home: 513-555-1234, Cell: 513-555-9876, Work: 513-555-3456

Answer Required

Emergency Contact #2 and Relationship to Child*

Answer Required

Emergency Contact #2 Phone Numbers*

For example, Home: 513-555-1234, Cell: 513-555-9876, Work: 513-555-3456

Answer Required

Emergency Contact #3 and Relationship to Child*

Answer Required

Emergency Contact #3 Phone Numbers*

For example, Home: 513-555-1234, Cell: 513-555-9876, Work: 513-555-3456

Answer Required

Facts concerning the child's medical history including allergies, medications and any physical impairment to which the school or physician should be alerted:*

Answer Required

Preferred Doctor:*

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Doctor's Phone Number:*

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Preferred Dentist:*

Answer Required

Dentist's Phone Number:*

Answer Required

Preferred Local Hospital:*

Answer Required

Grant or Refuse Consent for Treatment*

Answer Required

A. 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 the above named doctor or in the event the designated preferred physician is not available, by another licensed physician or 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 other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

B. 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:

If you do not consent for emergency medical treatment of your child, please write what actions you would like school authorities to take (in the event that you are not able to be contacted):

Answer Required

I certify that the information I have provided on this application is factually true and honestly presented.

Parent/Guardian Signature*

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Date*

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