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

Physician _______________________ Phone (_  )_____________

Dentist ________________________ Phone(__)_____________

Medical Specialist __________________ Phone (___)_____________

Local Hospital _________________ Emergency Rm. (___)_____________

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.

The authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity 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 ________________________________________ 

Zip __________

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 _______________________________ Zip ______________