Emergency Medical Authorization Form

Please print and complete this form with signatures in the appropriate sections.
Forms can be emailed to morganacademysummercamp@gmail.com or brought to the first day of camp.

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 or guardians cannot be reached.


STUDENT INFORMATION:
Student Name: _____________________________________________
Grade: _____ Sex: _____ Date of Birth: ____________________
Street Address: ________________________ Apt/Unit# ________
City: ___________________________ State: ____ Zip: ________

RESIDENTIAL PARENT OR GUARDIAN INFO:
Mother’s Name:_____________________________________________
Daytime Phone: ____________________ Cell: _________________
Father’s Name:_____________________________________________
Daytime Phone: ____________________ Cell: _________________

OTHER RELATIVE OR CHILD-CARE PROVIDER:
Name: _____________________________________________________
Relationship: _____________________________________________
Daytime Phone: ____________________ Cell: _________________
Street Address: ________________________ Apt/Unit# ________
City: ___________________________ State: ____ Zip: ________

EMERGENCY INFORMATION:
Important: Facts concerning the child’s medical history, including allergies, medications being taken, any physical impairments to which a physician should be alerted.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

YES, I hereby give consent for the following medical care providers and local hospital to be called:
Doctor’s Name:__________________________ Phone: ________________
Dentist’s Name:__________________________ Phone: ________________
Specialist’s Name:________________________ Phone: ________________
Hospital: ____________________ Emergency Room: _________________
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 above-named doctors, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my 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.

NO, 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:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

STUDENT ACCESS:
YES, the following adults have permission to pick up my child (the school may require identification from these individuals):
Name: _____________________________________________________
Name: _____________________________________________________
Name: _____________________________________________________

NO, the following individuals may not pick up my child (if a custody order/restriction exists, please provide a copy to the school):
Name: __________________________________________________________
Name: __________________________________________________________
Name: __________________________________________________________

AUTHORIZATION:
Parent/Guardian Name: ________________________________________________

Signature:_______________________________ Date:_________________