Medical Release and Consent to Treatment of Child

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    Medical Release and Consent to Treatment of Child

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    I have read, understood and consent to the following concerning my child.

    1. First-Aid/Emergency Treatment:

    Without limiting other emergency powers that may be provided by law, I authorize school personnel to administer first aid to my child if the school administration deems it necessary and appropriate to preserve the life, limb or well-being of my child. If the school administration believes, in its sole discretion, that a medical necessity exists beyond that which can reasonably be dealt with on school grounds by school personnel, I authorize the school to contact and engage qualified medical personnel and arrange for emergency treatment of my child, including transportation either by school staffor by professional transport for medical dental, surgical or hospital care or diagnosis, and I consent to that treatment formy child. Arrangements for treatment will be made in the following order of priority: 1) The "emergency physician" listed above; 2) the "primary physician" listed above; 3) another physician or health-care professional licensed by the State of California. I understanc and agree that I will be financially responsible for any such medical treatment.

    2. Medical Supervision/Administration of Medicines

    I understand that the school is not legally obligated to store or administer medication for students and will not do so, either on a temporary or ongoing basis, except by special agreement. If I have indicated, by signing this consent below, that the school may administer medications to my child, and if the school has agreed to administer medications by signing this consent below, I authorize the school to administer the medicines listed on this form, as indicated, but recognize that the school does not thereby undertake any ongoing duty to administer drugs or medicine, or to supervise or participate in any self-medication or medical program or ongoing, routine or non-emergency needs of my child, all of which remain my responsibility. Before any medication is given by the school, I will provide those medications in their original pharmacy containers, with the child's name and doctor's instructions on the label, and I will provide a written, signed authorization from a physician, including complete instructions.

    3. Release of Student to Qualified Emergency/Medical Personnel and Third Parties

    Without limiting other emergency powers as may be allowed by law, in the event of disaster or medical necessity involving the life, limb or well-being of my child in which it is necessary in the opinion of the school administration to transport my child from school properly, or if it is necessary to evacuate the school grounds, the school will make a reasonable effort (in view of the nature of the necessity) to first contact a parent or legal guardian. If no parent/legal guardian is available, I authorize the school to release my child into the custody of third parties for the purpose of transporting my child from school grounds and arranging for such care as my child may need, in the following order of priority: 1) the persons listed above as emergency contacts; 2) gualified medical/emergency professionals; 3) another responsible adult

    4. Gathering, Use and Release of Medical Information

    Without limiting other emergency powers that may be provided by law, in the event of disaster or medical emergency, I specifically authorize the gathering, use and release to, rom, and among the school personnel and to, from and among any medical professionals, of any medical information reasonably necessary to provide the emergency medical care and otherwise ensure the life, limb, and well-being of my child, including without limitation, the information contained in this form, until I can reasonably be notified and take custody of my child.

    I understand that this information will be requested, gathered and/or released only for the purpose of providing first-aid or emergency care necessary in the absence of a parent or legal guardian, or as otherwise allowed by law.

    5. School Athletics

    As a condition of participating in school athletics, the school reserves the right to obtain medical information regarding any physical or emotional condition or ijury that pertains to my child's ability to participate safely and constructively in school sports, and to require a written medical clearance at any time before my child may participate in, or return to participation in, school sports activities during the school year. This information will be used solely for the purpose of evaluating my child's ability to participate in school sports activities and will not be obtained by or disseminated to any third parties, except the school's coaches, administrators, trainers and athletic staff, and only for these purposes or as otherwise allowed by law.

    NOTE: ALL MEDICINES TO BE TAKEN ON SCHOOL GROUNDS, WHETHER SELF-ADMINISTERED OR ADMINISTERED BY THE SCHOOL (IF SCHOOL AGREES TO DO SO), MUST BE ARRANGED FOR IN ADVANCE, AND MUST BE PROVIDED IN THEIR ORIGINAL PHARMACY CONTAINER, INCLUDING THE CHILD'S NAME AND DOCTOR'S INSTRUCTIONS.

    THE SCHOOL WILL NOT ADMINISTER MEDICINES UNLESS A PHYSICIAN'S WRITTEN AND SIGNED AUTHORIZATION, INCLUDING COMPLETE INSTRUCTIONS, IS ATTACHED TO THIS FORM

    In consideration of the arrangement indicated in this consent, the undersigned hereby releases and discharges the Archdiocese of San Francisco, its constituent organizations, including but not limited to The Roman Catholic Welfare Corporations, the Department of Catholic Schools and the school, and their respective officers, agents and employees for any and all claims for personal injuries or property damage that I or my child may suffer as a result of this arrangement whether or not such injuries or damages be caused by the negligence (whether active or passive) of any of the entities or individuals named or described above, excepting only injuries or damage resulting from Archdiocese's willful misconduct. I authorize and request the school to adminster the above medications to my child on these terms.

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    General Terms of Parental Consent

    1. General Terms of Parental Consent:

    CONFIDENTIAL MEDICAL OR EDUCATIONAL INFORMATION AS SET FORTH IN THIS FORM WILL BE GATHERED, USED AND DISSEMINATED ONLY BY THE PERSONS AND ONLY FOR THE PURPOSES SET FORTH HEREIN, OR AS OTHERWISE ALLOWED BY LAW. THIS AUTHORIZATION IS EFFECTIVE ONLY FOR THE SCHOOL YEAR LISTED ABOVE AND WILL EXPIRE ON JUNE 15, 2015. IT MAY BE REVOKED AT ANY TIME BY A WRITING SIGNED BY THE PARENTS. HOWEVER, IF REVOKED, THE SCHOOL RESERVES THE RIGHT TO SUSPEND OR TERMINATE THE ATTENDANCE OF THE CHILD AT THE SCHOOL. I AGREE TO AND CONSENT TO THE ACTIONS SET FORTH HEREIN AND HEREBY GRANT AUTHORIZATION OF THE SCHOOL TO OBTAIN AND USE MEDICAL INFORMATION AND RECORDS BY THE PERSONS, FOR THE PURPOSES, AND DURING THE TIME SET FORTH ABOVE. I UNDERSTAND THAT I HAVE THE RIGHT TO RECEIVE A TRUE COPY OF THIS AUTHORIZATION, BY MY SIGNATURE, I ACKNOWLEDGE THAT A TRUE COPY OF THIS AUTHORIZATION HAS BEEN RECEIVED BY ME.
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