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Microsoft word - authorization for em#5b3aed.doc

SANTA MONICA HIGH SCHOOL Authorization for Emergency Medical Care (Waiver) Student I.D.#_______________SPORT(S) ≤Fall Season: ≤Winter Season: ≤Spring Season: PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for student athletes who become ill or injured while under schoolauthority when parent or guardian cannot be reasonably reached? NAME (LAST) (FIRST) (MI)_____ Grade____________ ADDRESS (Residence) Sex Age Date of Birth CITY, STATE & ZIP Home Phone Student Cell Phone Parent/Guardian Name Home Phone Work/Cell Phone Parent/Guardian Name Home Phone Work/Cell Phone Family Doctor Phone Family Dentist Phone Health Insurance Co. Policy ID Agent Phone Name and phone number of person other than parent/guardian who is authorized to approve emergency medical treatment: In the event reasonable attempts to contact me/us at above locations or other person(s) named above, full authorization is given for (1) the administration of any treatment deemedto be necessary by a licensed trainer or medical practitioner and (2) the transfer of son/daughter or ward to any licensed trainer, medical practitioner and (3) the transfer ofson/daughter or ward to any licensed hospital or emergency clinic reasonably accessible. It is understood that this authorization is given in advance of any specific diagnosis,treatment or hospital care being required but it is given to provide authority and power on the part of school authorities and aforesaid agent(s) to give reasonable care. Facts aregiven below concerning the student’s medical history, which a medical practitioner should know.
AUTHORIZATION FOR MEDICATION – Will not be given without your signature. If left blank or crossed out, Tylenol or Advil will NOT be made available to yourchild. I hereby request that the school nurse make available the following medication(s) to my child as prescribed by the District physician consultant: Medication (cross out if do NOT want given) 1 tablet (if student weighs less than 100 pounds) Ibuprofen (Motrin, Advil) – 200mg/tablet 2 tablets (if student weighs 100 pounds or more) Any previous significant medical problems? Authorization for Emergency Medical Care (Waiver) Student I.D.#________________ SPORT(S) ≤Fall Season: ≤Winter Season: ≤Spring Season: PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for student athletes who become ill or injured while under schoolauthority when parent or guardian cannot be reasonably reached.
NAME (LAST) (FIRST) (MI)_____ Grade____________ ADDRESS (Residence) Sex Age Date of Birth CITY, STATE & ZIP Home Phone Student Cell Phone Parent/Guardian Name Home Phone Work/Cell Phone Parent/Guardian Name Home Phone Work/Cell Phone Family Doctor Phone Family Dentist Phone Health Insurance Co. Policy ID Agent Phone Name and phone number of person other than parent/guardian who is authorized to approve emergency medical treatment: In the event reasonable attempts to contact me/us at above locations or other person(s) named above, full authorization is given for (1) the administration of any treatment deemedto be necessary by a licensed trainer or medical practitioner and (2) the transfer of son/daughter or ward to any licensed trainer, medical practitioner and (3) the transfer ofson/daughter or ward to any licensed hospital or emergency clinic reasonably accessible. It is understood that this authorization is given in advance of any specific diagnosis,treatment or hospital care being required but it is given to provide authority and power on the part of school authorities and aforesaid agent(s) to give reasonable care. Facts aregiven below concerning the student’s medical history, which a medical practitioner should know.
AUTHORIZATION FOR MEDICATION – Will not be given without your signature. If left blank or crossed out, Tylenol or Advil will NOT be made available to yourchild. I hereby request that the school nurse make available the following medication(s) to my child as prescribed by the District physician consultant: Medication (cross out if do NOT want given) 1 tablet (if student weighs less than 100 pounds) Ibuprofen (Motrin, Advil) – 200mg/tablet 2 tablets (if student weighs 100 pounds or more) Any previous significant medical problems?

Source: http://www.smmusd.org/samohi/Activities/sports/pdf/EmergencyMedicalCare.pdf

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