EmailMe Form - Emergency Medical Authorization

Name of Child *

First Last

Date of Birth *

MM / DD / YYYY

Home
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Emergency Contacts

Please list names and contact information in the order you would like them to be contacted.

Child's Parent/Guardian 1 Name *

First Last

In the event of an emergency, we will contact this person first.

Parent/Guardian 1 Home Phone

### - ### - ####

Parent/Guardian 1 Work Phone

### - ### - ####

Parent/Guardian 1 Cell Phone

### - ### - ####

Child's Parent/Guardian 2 Name *

First Last

In the event of an emergency, we will contact this person second.

Parent/Guardian 2 Home Phone

### - ### - ####

Parent/Guardian 2 Work Phone

### - ### - ####

Parent/Guardian 2 Cell Phone

### - ### - ####

Other Adult (non-parent)'s Name *

First Last

In the event of an emergency, we will contact this person third.

Other Adult's Home Phone

### - ### - ####

Other Adult's Work Phone

### - ### - ####

Other Adult's Cell Phone

### - ### - ####

Please list any additional information you wish to provide regarding the contacts listed above (e.g., call cell first).

Child's Medical Providers

Please provide below the name and phone number of the doctor and dentist most familiar with your child's care.

Child's Physician Name

First Last

Physician's Phone Number

### - ### - ####

Child's Dentist Name

First Last

Dentist's Phone Number

### - ### - ####

Persons to Whom the Child May Be Released

Your child will only be released to the persons you list below or to a person who you authorize in writing on a special occasion. Please be aware that people we are not familiar with may be asked to show identification. In the event an authorized person is deemed by staff to be potentially dangerous to your child, we will not release your child to that person and will instead contact you or another person on your list. This policy is required by DHS for the protection of our students.

First Authorized Adult's Name

First Last

Please list the name and phone number of any person other than the child’s parents to whom the child may be released.

First Adult's Phone Number

### - ### - ####

Second Authorized Adult's Name

First Last

Please list the name and phone number of any person other than the child’s parents to whom the child may be released.

Second Adult's Phone Number

### - ### - ####

Third Authorized Adult's Name

First Last

Please list the name and phone number of any person other than the child’s parents to whom the child may be released.

Third Adult's Phone Number

### - ### - ####

Parent's Name

First Last

Please enter your (parent/guardian) name to sign electronically and indicate that you authorize the contacts specified above to pick up your child.

Date Signed

MM / DD / YYYY

Emergency Treatment Authorization or Refusal

Either option I or option II below must be completed. If option II is selected, you must provide a notarized Refusal of Treatment Form.

*

Option I - Authorization to obtain emergency medical treatment

Option II – Withholding of authorization to obtain emergency medical treatment

If attempts to reach the above contacts have been unsuccessful, I hereby give my consent for the admission of any treatment deemed necessary by the physician and/or dentist specified above, or the transfer of the child to the following hospital:

Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician or dentist should be alerted:

Parent's Name

First Last

Please enter your (parent/guardian) name to sign electronically and indicate that you authorize MSF to seek emergency medical treatment of your child.

Date Signed

MM / DD / YYYY

Option II – Withholding of authorization to obtain emergency treatment.

First Last

Please enter your (parent/guardian) name to sign electronically and indicate that you are withholding permission for emergency medical treatment of your child. If this option is selected, please contact the MSF office at 615-794-0567 to obtain a Refusal of Treatment Form which must be completed and notarized.

Date Signed

MM / DD / YYYY