Emergency Medical Authorization and Permission Form

** This form is for students in grades 4 - 12 only ** It will be kept on file September 2013-August 2014. Please complete a new form yearly. Fill out one form per student.

    Personal Information

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    Medical History

    Please fill out each section completely as it applies to your child.
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    Medical Care Information

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

    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 doctor or in the event the designated preferred doctor is not available, by another licensed physican, 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.
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    Cell Phone/Email consent for student

    I give consent for my child to be contacted by cell phone or email by WUMC church personnel.
    This is a required question
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