Saint Pope John XXIII PSR Emergency Medical Authorization 2025-2026

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Please fill out one for each child.
If the question does not apply to you please type "None or N/A" in the box.

Student Last Name *

Student First Name *

Student Grade *

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

Youth Formation

Student Primary Address *

Student Primary Phone Number *

To enable parents/guardians to authorize the provision of emergency treatment for a child who becomes ill or injured while attending the St. Pope John XXIII PSR program. Location: Our Lady of Mount Carmel Parish Family Center, 29 Erie Street, Niles, Ohio 44446

Consent

I hereby give my consent for the administration of any treatment deemed necessary by the following doctors or in the event the designated preferred practitioner is not available, by another licensed physician or dentist and the transfer of the child to the listed hospital or any hospital reasonable accessible.

Name of Preferred Physician *

Name of Preferred Dentist *

Name of Preferred Hospital *

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 surgery. Every effort will be made to contact the Parent/Guardian first.

Is this child covered by hospitalization and medical insurance *

Yes

No, I assume the responsibility for the cost of the hospitalization and medical care for my child.

If yes, please indicate Policy Number and who it is Issued By *

Any other medical information concerning medications, allergies, illness, etc. *

Please describe any special medical instructions (include all allergies, allergic reactions to medicines, food allergies) or other special circumstances concerning your child in an emergency situation *

Please list another contact and their phone number in the event we cannot reach you *

Name of person filling out this form *

Date form was filled out *

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