Fillable HEALTH ALERT EMERGENCY MEDICAL AUTHORIZATION (Plain Local Schools)

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HEALTH ALERT EMERGENCY MEDICAL AUTHORIZATION (Plain Local Schools)

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EMERGENCY MEDICAL AUTHORIZATION
PURPOSE - To enable parents 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. This information may be shared with the educational team to best meet your child’s needs.
Student Name
______________________________________________ Phone # ___________________________ Bus # __________________
Address
__________________________________________________ School District _____________________________________________
_________________________________________________________ School Attending ___________________________________________
Address Change Y N Birth Date
____________________________ Sex M F Grade _______ Home Room _______________________
Residential Parent or Guardian
Mother
__________________________________ Day Ph # ________________________________ Cell # _______________________________
Email _____________________________________________________________________ Pager # _____________________________
Father
__________________________________ Day Ph # ________________________________ Cell # _______________________________
Email _____________________________________________________________________ Pager # _____________________________
Other Name
_____________________________ Day Ph # ________________________________ Cell # _______________________________
Name of Relative or Childcare Provider
_______________________________________________________________________________________
Address
__________________________________________________ Phone # ___________________________________________________
__________________________________________________________ Relationship _______________________________________________
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor
____________________________________________________ Phone # ___________________________________________________
Dentist
____________________________________________________ Phone # ___________________________________________________
Medical Specialist
__________________________________________ Phone # ___________________________________________________
Hospital
__________________________________________________ Phone # ___________________________________________________
Below check any current health condition that may require attention during the school day:
Allergies(bespecic) Otherhealthconditions(bespecic) ________________________
Foods _______________________ EpiPen ___ Yes ___ No ______________________________________________________
Medicines _________________________________________ Previoussurgeries(bespecic)_____________________________
Bee Stings EpiPen ___ Yes ___ No ______________________________________________________
Other _____________________________________________ Previous concussion/head injury-year _______________________
Asthma Uses emergency inhaler ___ Yes ___ No Hearing problems Has hearing aids ___ Yes ___ No
Cancer Visionproblems(bespecic) ______________________________
Diabetes ______________________________________________________
Seizures Wears: Glasses Contacts
Heartproblems(bespecic) ______________________________ ADD/ADHD
______________________________________________________ Behavior/emotional problems _____________________________
Physicaldisability(bespecic) ____________________________ ______________________________________________________
______________________________________________________ No current health conditions
List all medications and dosages your child receives on a continual basis: ____________________________________________________________
________________________________________________________________________________________________________________________
PLEASE COMPLETE PART I or PART II — NOT BOTH
Part I — TO GRANT CONSENT
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 the designated physician or dentist, or in the event the designated practitioner is not available, by another licensed physician or dentist;
and
(2)thetransferofthechildtothedesignatedhospitaloranyhospitalreasonablyaccessible.
This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
Date
_______________________________ Parent or Guardian Signature ________________________________________________________
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 no action or to:
____________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Date
_______________________________ Parent or Guardian REFUSAL Signature ______________________________________________
HEALTH FORM B - Revised LLS 8/09
P—25
HEALTH ALERT
Section 3313.712, Ohio Revised Code
(Pursuant to H.B. 639)
(A) Annually,theboardofeducationofeachcity,exemptedvillage,local,andjointvocationalschooldistrictshall,before
therstdayofOctober,haveprovidedtotheparentorlegalguardianofeverypupilenrolledinschoolsundertheboard's
jurisdiction,anemergencymedicalauthorizationformthatisanidenticalcopyoftheformcontainedindivision(B)of
this section. Thereafter, the board shall, within thirty days after the entry of any pupil into a public school in this state
for
thersttime,providetheparentorlegalguardianofsuchpupil,eitheraspartofanyregistrationformwhichisin
useinthedistrict,orasaseparateform,anidenticalcopyoftheformcontainedindivision(B)ofthissection.
When
theformisreturnedtotheschoolwithPartIorPartIIcompleted,theschoolshallkeeptheformonle,andshall
send the form to any school of a city, exempted village, local, or joint vocational school district to which the pupil is
transferred. Upon request of his parent or guardian, authorities of the school in which the pupil is enrolled may permit
such
parentorguardiantomakechangesinapreviouslyledform,ortoleanewform.
If a parent or guardian does not wish to give such written permission, he shall indicate in the proper place on the form
the procedure he wishes school authorities to follow in the event of a medical emergency involving a child.
Even if a parent or guardian gives written consent for emergency medical treatment, when a pupil becomes ill or is
injured and requires emergency medical treatment while under school authority, or while engaged in an extracurricular
activity authorized by the appropriate school authorities, the authorities of the school in which the pupil is enrolled
shall make reasonable attempts to contact the parent or legal guardian before the treatment is given. The school shall
present
thepupil'semergencymedicalauthorizationformoracopythereoftothehospitalorpractitionerrendering
treatment.
Nothing
inthissectionshallbeconstruedtoimposeliabilityonanyschoolofcialorschoolemployeewho,ingood
faith, attempts to comply with this section.
(B) The
emergencymedicalauthorizationformprovidedforindivision(A)ofthissectionisasfollows:
(See reverse side)
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HEALTH ALERT EMERGENCY MEDICAL AUTHORIZATION (Plain Local Schools)

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Completed 28 May 2021

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