Emergency Medical Authorization Form

Saint Mary’s Parish Church

CCD Religious Education Office

Grade: ______ Room: _____

Student Name: ________________________ Birth Date: Mth: _____ Day: _____ Year: ______

Address: _________________________________________ Home Phone: ________________

Mother’s or Guardian’s Name: _____________________ Email: _________________________

Address: ______________________________Cell Phone: _____________________________

Where Employed: _______________________ Work Phone: __________________ Ext: _____

Father’s or Guardian’s Name: _______________________ Email: ________________________

Address: ________________________________ Cell Phone: ____________________________

Where Employed: _______________________ Work Phone: ___________________ Ext: _____

IF ABOVE PARENTS/GUARDIANS CANNOT BE REACHED, PLEASE CALL:

(A) First Contact’s Name: ______________________ Relationship: _______________________

Address: _______________________________ Work Phone: _________________ Ext: ______

Home Phone: _________________________ Cell Phone: _____________________________

(B) Second Contact’s Name: ______________________ Relationship: ____________________

Address: _______________________________ Work Phone: _________________ Ext: ______

Home Phone: _________________________ Cell Phone: _____________________________

In case of accident or serious illness, I request the parish to contact me or my designate. If this cannot be done, I authorize the parish to call the physician or dentist listed on this form and to follow his/her instructions. If the physician or dentist named cannot be reached, the parish may seek medical services that seem necessary. I realize the parish does not assume responsibility for payment of medical expenses.

Signature of Parent or Guardian: ____________________________ Date: __________________

In the event emergency treatment is needed, I give the hospital, its authorized personnel and/or physician permission to treat my son/daughter as necessary.

Signature of Parent or Guardian: ____________________________ Date: __________________

Allergies: _____________________________________________________________________

Medical Problems: ______________________________________________________________

Taking Medication: Yes: ______ No: ______ If Yes, Type: ________________________________

Reason: (Medications will be administered at parish only according to current parish policies): ______________________________________________________________________________

Physician/clinic: _______________________________________ Phone: __________________

Dentist: ______________________________________________ Phone: __________________

Hospital Preference: _____________________________________________________________

OR

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring medical treatment, I wish the parish authorities to take no action or to: _____________________________________________________________________________

Signature of Parent or Guardian: ___________________________ Date: __________________