Emergency Medical Authorization Form

SPORT: ______

TROY CITY SCHOOLS

EMERGENCY MEDICAL AUTHORIZATION FORM

Student Name: / Telephone:
Address: / City/State/Zip:
School: / Grade:

Purpose - To enable parent 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.

Residential Parent or Guardian:
Mother's Name (first, last): / Daytime Phone:
Father's Name (first, last): / Daytime Phone:
Other's Name (first, last) / Daytime Phone
Name of Relative or Childcare Provider:
Name (first, last) / Relationship
Address City/State/Zip / Daytime Phone

PART I OR PART II MUST BE COMPLETED

PART I: TO GRANT CONSENT

I hereby give consent for the following medical care providers and local hospital to be called:

Physician: / Phone:
Dentist: / Phone:
Medical Specialist / Phone
LocalHospital / Emergency Room Phone

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 preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the 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 thenecessity for such surgery, are obtained prior to the performance of such surgery.

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

______

Date: ______Signature of Parent/Guardian______

Address: ______

City/State/Zip: ______

PART II: REFUSAL TO CONSENT

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: ______

Date: ______Signature of Parent/Guardian______

Address ______

City/State/Zip______

ATHLETIC INJURIES

Due to the State Auditor’s interpretation of the State Law, School Athletic Departments are no longer able to spend monies on individuals injured in school athletic activities. The auditors’ reason is that athletics are voluntary programs and the individuals participating should be financially responsible for any injuries. This is an unfortunate circumstance but we must abide by this ruling.

To be sure that you have been made aware of this policy, we are asking you to sign the release form, below, and return it to the coach responsible for the athletic activity in which your son or daughter participates during this school year.

STATEMENT OF RELEASE

We, the parents (legal guardian) of ______who is participating in athletics for the Troy School System during the school year of ______do hereby release the Troy Athletic Department from any financial responsibility associated with an injury to the individual mentioned above while he or she is participating in any athletic activities for the Troy Schools.

______

Signature of father or male legal guardianDate

______

Signature of mother or female legal guardianDate

As a participant in the athletic program for the Troy Schools, I also release the Troy Athletic Department from any financial obligations associated with an injury which I may receive while participating in any athletic activities for the Troy Schools.

______

Signature or AthleteDate