7:300-E3 Authorization for Medical Treatment

To be submitted to the Superintendent. (please print)

Student ____________________________________

Sport/Activity ________________________________

Parent/Guardian _______________________________

Home address __________________________________

Home phone ____________________ Cell phone ___________________

Physician _______________________Physician phone ____________

Medical Information: (list allergies, medications, conditions and any known restrictions)

In the event of a medical emergency and if reasonable attempts to contact me using the telephone numbers listed above are unsuccessful:

I, as parent or legal guardian of the above student, do hereby authorize:

1. Treatment by a licensed medical physician of my child/ward in the event of a medical emergency that, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, and

2. Transfer of my child/ward to any hospital reasonably accessible at my expense.

Parent/Guardian signature ______________________________

Date ________________________

Date Approved: 06/24/2009