AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT Parent's Name * First Name Last Name Child's Name * First Name Last Name Name of School * Name of Relative * First Name Last Name Telephone Number of Parent * (###) ### #### In case of a medical emergency concerning my child, at a time when I or "Name of Relative" below, cannot be notified, I authorize school officials to consent to any necessary X-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care. * First Name Last Name CHILD'S DOCTOR INFO Doctor's Name * First Name Last Name Doctor's Phone: * (###) ### #### CHILD'S INFO My child is currently taking the following medication: Provide information if applicable. My child has the following allergies: Provide information if applicable. Anything else we need to know? Today's Date: * MM DD YYYY Signature of Parent Legal jargon here. Thank you!
