Emergency Medical Authorization

St.Michael Pre-School/PSR Program 2011-2012

Family Name:  ____________________  Father ______________  Mother __________

Father’s CellPhone ___________________  Mother’s Cell Phone:   _______________________

Home Phone:  _________________________

Home Address ______________________________________ City ___________________ Zip ___________

 If the persons named above are not available in the event of an emergency, notify:

Name: _____________________________ Relationship __________________ Phone ________________

Name: _____________________________ Relationship __________________ Phone ________________

Personal health/accident insurance carrier ___________________________ Policy # _________________

First Child:   ___________________________ Birth date: _____________ Age_____ Sex   ______

Second Child:  _________________________  Birth date:  _____________ Age _____ Sex _______

Third Child:   __________________________  Birth date:  _____________ Age ______ Sex ________

Fourth Child:   __________________________ Birth date:  _____________ Age _____ Sex _______

Fifth Child:   ___________________________ Birth date:  _____________ Age _____ Sex ______

Part I or Part II Below Must Be Completed.

Part 1:   To Grant Consent

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. (Please be sure to sign your name at the bottom of the reverse side.) 

In the event reasonable attempts to contact me at _________________ (phone #) or _________________ (other parent or guardian) at ___________________ (phone #) have been unsuccessful, I give my consent for:    first child, named:  __________1)the administration of any treatment deemed by Dr. ____________________(preferred physician) or Dr. ________________________ (preferred dentist) or in the event this designated practitioner is not available, by another licensed physician or dentist;   and 2)  the transfer of the child to _________________ hospital.   Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

_______________________________________________________________________

Second child:  Named ____________________:    1)the administration of any treatment deemed by Dr. ____________________(preferred physician) or Dr. ________________________ (preferred dentist) or in the event this designated practitioner is not available, by another licensed physician or dentist;   and 2)  the transfer of the child to _________________ hospital.    Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

_______________________________________________________________________

_______________________________________________________________________

 Third Child, named:  _________________:    1)the administration of any treatment deemed by Dr. ____________________(preferred physician) or Dr. ________________________ (preferred dentist) or in the event this designated practitioner is not available, by another licensed physician or dentist;   and 2)  the transfer of the child to _________________ hospital.   Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 _______________________________________________________________________

Signature of Parent/Guardian _____________________________________Date _________________

(Do not complete Part II if you have completed Part I)

Part II:    Refusal  to Consent

I do not give my consent for emergency medical treatment of my child(children).   In the event of illness or injury requiring medical treatment, I wish the PSR staff to take no action or to:

 ________________________________________________________________________