Unity Junior High Emergency Medical Authorization 2018-19
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 and guardians cannot be reached in a timely manner. Every effort will be made to provide medical services as needed and as designated below.

List parent(s) first and then list family or friends. You may NOT exclude a parent if there is joint custody of the child unless you show court documentation of sole custody belonging to either parent.

If any of the fields do not apply to you, put NA.

Student Name (Last, First)
Your answer
Grade
Street Address
Your answer
City
Mothers Name (Last, First)
Your answer
Mother main phone number
Your answer
Mother secondary phone number
Your answer
Fathers Name (Last, First)
Your answer
Father main phone number
Your answer
Father secondary phone number
Your answer
Emergency contact #3 name & relation to student.
Your answer
Emergency contact #3 main phone number
Your answer
Emergency contact #3 secondary phone number
Your answer
Emergency contact #4 name & relation to student
Your answer
Emergency contact #4 main phone number
Your answer
Emergency contact #4 secondary phone number
Your answer
If unable to reach me at any of the above telephone numbers, I hereby give my consent for necessary treatment by Dr. ______________ *
Your answer
(S)He is our preferred physician. If not available, I give consent for necessary treatment by another licensed physician. I prefer treatment at _________ hospital. *
Your answer
At phone number _____________
Your answer
Electronic Signature - Type Full Name *
This Electronic Signature Verification Statement is intended to document a physical copy of my signature. This Emergency Medical Authorization shall continue in full force and in effect until CUSD #7 is advised in writing of any changes desired by the undersigned. I understand that any expenses incurred as a result of transportation and treatment will be my financial responsibility.
Your answer
Date
MM
/
DD
/
YYYY
Health Concerns
Your answer
Allergies
Your answer
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