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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 for "Student First Name"

Student Last Name*

Answer required for "Student Last Name"

Student Grade*

Answer required for "Student Grade"

Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Date of Birth*

Answer required for "Date of Birth"

Homeroom*

Answer required for "Homeroom"

Guardian 1 Name and Relationship*

Answer required for "Guardian 1 Name and Relationship"

Guardian 1 Phone Numbers*

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

Answer required for "Guardian 1 Phone Numbers"

Guardian 2 Name and Relationship

Answer required for "Guardian 2 Name and Relationship"

Guardian 2 Phone Numbers

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

Answer required for "Guardian 2 Phone Numbers"

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 for "Emergency Contact #1 and Relationship to Child"

Emergency Contact #1 Phone Numbers*

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

Answer required for "Emergency Contact #1 Phone Numbers"

Emergency Contact #2 and Relationship to Child*

Answer required for "Emergency Contact #2 and Relationship to Child"

Emergency Contact #2 Phone Numbers*

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

Answer required for "Emergency Contact #2 Phone Numbers"

Emergency Contact #3 and Relationship to Child*

Answer required for "Emergency Contact #3 and Relationship to Child"

Emergency Contact #3 Phone Numbers*

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

Answer required for "Emergency Contact #3 Phone Numbers"

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

Preferred Doctor:*

Answer required for "Preferred Doctor:"

Doctor's Phone Number:*

Answer required for "Doctor's Phone Number:"

Preferred Dentist:*

Answer required for "Preferred Dentist:"

Dentist's Phone Number:*

Answer required for "Dentist's Phone Number:"

Preferred Local Hospital:*

Answer required for "Preferred Local Hospital:"

Grant or Refuse Consent for Treatment*

Answer required for "Grant or Refuse Consent for Treatment"

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 for "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):"

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

Parent/Guardian Signature*

Answer required for "Parent/Guardian Signature"

Date*

Answer required for "Date"