Parental Authorization Forms - Document Library

TEMPLE ACADEMY EMERGENCY & ILLNESS INFORMATION

Student Name: *

(First Name Last Name)

Grade: *

Birthdate: *

/

Home Address: *

City: *

Zip: *

Home Phone: *

Mother/Guardian Name: *

(First Name Last Name)

Cell Phone: *

Email: *

Father/Guardian Name: *

(First Name Last Name)

Cell Phone: *

Email: *

Place of Work

Father’s Place of Work: *

Working Hours: *

Phone: *

Mother’s Place of Work: *

Working Hours: *

Phone: *

Emergency Contact (list someone locally)

Name: *

(First Name Last Name)

Address: *

Town: *

Phone: *

People who have permission to pick your child up from school:

Name: *

(First Name Last Name)

Phone: *

Name:

(First Name Last Name)

Phone:

The staff at Temple Academy has permission to administer non-aspirin pain reliever if needed: *

Yes

No

The staff at Temple Academy has permission to administer Tums if needed: *

Yes

No

First Aid Cream: *

Yes

No

Does your child have any unusual health conditions?: *

Yes

No

Other Allergies (if any):

(please indicate mild / severe allergy)

Physical Handicap (describe):

Family Doctor: *

Office Phone: *

Family Dentist: *

Office Phone: *

Health Insurance Co: *

Policy #: *

Policy Holder: *

AUTHORIZATION FOR EMERGENCY CARE TO MINORS

If emergency treatment is required, and the parents or legal guardians cannot be reached immediately, your signatures below authorizes Temple Academy staff to exercise their own judgment to call the physician or dentist named above. If the physician or dentist named above is not available, your signatures below:

Authorizes Temple Academy staff to transport the child to a hospital emergency room
Authorizes any x-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist
Authorizes any physician or dentist to call in necessary consultants, at his/her own discretion
Authorizes the release of any medical records regarding the Emergency Room visit to Temple Academy for its files

Your signatures below encourage Temple Academy staff and any physician or dentist to exercise his/her/their best judgment in any diagnosis or medical, dental, or surgical treatment.

This is a general authorization given in advance of any specific diagnosis or treatment being required and is not sufficient for the release of confidential information protected by Federal Law. Parents/guardians understand that Temple Academy does not assume responsibility for the payment of hospital, doctor, or ambulance fees. Parents/guardians understand it is his/her/their responsibility to keep the information on this card current.

Parent/Guardian Signature: *

(First Name Last Name)

Parent/Guardian Signature:

(First Name Last Name)

Emergency Information