AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

Parent's Name *
Parent's Name
Child's Name *
Child's Name
Name of Relative *
Name of Relative
Telephone Number of Parent *
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. *
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.
CHILD'S DOCTOR INFO
Doctor's Name *
Doctor's Name
Doctor's Phone: *
Doctor's Phone:
CHILD'S INFO
Provide information if applicable.
Provide information if applicable.
Today's Date: *
Today's Date:
Legal jargon here.