(please indicate mild / severe allergy)
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.