Pickens High School Athletics: Emergency Medical Authorization
Student's Name
Your answer
Date of Birth
MM
/
DD
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YYYY
Grade in 2017-2018 School Year
Address
Your answer
Emergency Phone Number
Your answer
Parent's/Guardian's Name
Your answer
Alternate Person
Your answer
Alternate Person's Phone Number
Your answer
PART 1 OR PART 2 MUST BE COMPLETED
Part 1 - To Grant Consent
In the event reasonable attempts to contact the parent's/guardian's or alternate person's at the appropriate phone numbers have been unsuccessful, I hereby give my consent to any member of the coaching staff of any treatment deemed necessary. I also grant consent to the coaches to transfer my child to Piedmont Mountainside Hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions or 2 other licensed physicians concurring in the necessity for such surgery are obtained before surgery is performed. Facts concerning the child's medical history including allergies, medications being taken and any physical impairment to which a physician should be alerted should be listed below:
Your answer
Part 1 Signature -
By entering your name below you are granting conset to the coaching staff to act in the best interest of your child if you or your alternate person can not be reached.
Your answer
Part 2 - Refusal of Consent
I do not give my consent for emergency treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the coaches to take no action. If l cannot be contacted, I wish the coaches to take no action or to:
Your answer
Part 2 Signature
By entering your name below you are refusing conset for the coahcing staff or anyone else to provide medical treatment to your child without your consent
Your answer
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