Forms and payments can be mailed to:

P.O. Box 1281

Shepherdstown, WV 25443

or brought to Morgan Academy between 9:00 a.m. and 3:00 p.m. at:

8505 Shepherdstown Pike

Shepherdstown, WV 25443

Emergency Medical Authorization Form

Please print and complete this form with signatures in the appropriate sections.

This form can be emailed to summercamp@morganacademyWV.com or brought to the first day of camp.

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.

STUDENT INFORMATION:

Student Name: _____________________________________________

Grade: _____ Sex: _____ Date of Birth: ____________________

Street Address: ________________________ Apt/Unit# ________

City: ___________________________ State: ____ Zip: ________

RESIDENTIAL PARENT OR GUARDIAN INFO:

Mother’s Name:_____________________________________________

Daytime Phone: ____________________ Cell: _________________

Father’s Name:_____________________________________________

Daytime Phone: ____________________ Cell: _________________

OTHER RELATIVE OR CHILD-CARE PROVIDER:

Name: _____________________________________________________

Relationship: _____________________________________________

Daytime Phone: ____________________ Cell: _________________

Street Address: ________________________ Apt/Unit# ________

City: ___________________________ State: ____ Zip: ________

EMERGENCY INFORMATION:

Important: Facts concerning the child’s medical history, including allergies, medications being taken, any physical impairments to which a physician should be alerted.

_________________________________________________________________________

_________________________________________________________________________

YES, I hereby give consent for the following medical care providers and local hospital to be called:

Doctor’s Name:__________________________ Phone: ________________

Dentist’s Name:__________________________ Phone: ________________

Specialist’s Name:________________________ Phone: ________________

Hospital: ____________________ Emergency Room: _________________

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 above-named doctors, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

NO, 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 the following action:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

STUDENT ACCESS:

YES, the following adults have permission to pick up my child (the school may require identification from these individuals):

Name: _____________________________________________________

Name: _____________________________________________________

Name: _____________________________________________________

NO, the following individuals may not pick up my child (if a custody order/restriction exists, please provide a copy to the school):

Name: __________________________________________________________

Name: __________________________________________________________

Name: __________________________________________________________

AUTHORIZATION:

Parent/Guardian Name: ________________________________________________

Signature:_______________________________ Date:_________________