2019-2020 Tuslaw Emergency Medical Form Athletics
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 First Name *
Your answer
Student Last Name *
Your answer
Grade- Please enter grade number. For kindergarten enter the number 0. *
Your answer
Birthdate *
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Address *
Your answer
Address Change *
Preferred Phone Number *
Your answer
Bus #
Your answer
School District *
Your answer
School Attending *
Your answer
Homeroom
Your answer
Sex *
Residential Parent or Guardian:
Mother First Name
Your answer
Mother Last Name
Your answer
Mother Day Phone #
Your answer
Mother Cell Phone #
Your answer
Mother Email Address
Your answer
Father First Name
Your answer
Father Last Name
Your answer
Father Day Phone #
Your answer
Father Cell Phone #
Your answer
Father Email Address
Your answer
1. Other Contact First Name
Your answer
1. Other Contact Last Name
Your answer
1. Relationship
Your answer
1. Day Phone #
Your answer
1. Cell Phone #
Your answer
2. Other Contact First Name
Your answer
2. Other Contact Last Name
Your answer
2. Relationship
Your answer
2. Day Phone #
Your answer
2. Cell Phone #
Your answer
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor Name *
Your answer
Doctor Phone # *
Your answer
Dentist Name *
Your answer
Dentist Phone # *
Your answer
Medical Specialist Name
Your answer
Medical Specialist Phone #
Your answer
Hospital Name *
Your answer
Hospital Phone # *
Your answer
Check below any current health conditions that may require attention during the school day:
Allergies - Food- Please be specific
Your answer
EpiPen for Food
Allergies - Medicine- Please be specific
Your answer
Allergies - Bee Sting
EpiPen for Bee Sting
Other Allergies
Your answer
Asthma *
Asthma- Use emergency inhaler
Asthma- Inhaler will be at School
Cancer *
Diabetes *
Seizures *
Heart Problems *
If heart problems please be specific below
Your answer
Physical Disability *
If Physical Disability please be specific below
Your answer
List all medications and dosages your child receives on a continual basis:
Your answer
Other health conditions- please be specific
Your answer
Previous Surgeries- Include Date
Your answer
Previous concussions/ head injury- Include year
Your answer
Hearing Problems
Has hearing aids
Vision Problems
Wears
ADHD
Behavior or Emotional Problems
Behavior or Emotional Problems- Please Explain
Your answer
Bleeding Disorder *
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 dentists, 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- PART 1
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Parent or Guardian Signature- PART 1
By placing your name and submitting the form you are agreeing to the terms.
Your answer
PART II- 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:
Your answer
Date- PART II
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Parent or Guardian Signature- PART II
By placing your name and submitting the form you are agreeing to the terms.
Your answer
Tuslaw Local Schools Athletic Code Conduct https://goo.gl/DYUgZ5 *
Required
Tuslaw Local Schools Drug Testing Policy https://goo.gl/C8ezmo *
Required
Ohio Department of Health Concussion Information Sheet https://goo.gl/ER7AHZ *
Required
Required
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