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Authorization to School, Emergency Medical Treatment for Minor (United States)

This is a form is authorization for a school to treat a minor for an emergency in the United States. The form provided here is simply a sample of what the actual form looks like.



I, ______________________,

of __________________________________________ (address),

am the ______________________ (father/mother/legal guardian)

of ______________________, a minor,

of _____________________________________ (address),

who attends ____________________________________ (name of school),

located at ________________________________________ (address).

In the event all reasonable attempts by authorized school personnel to contact me at _____________ (phone number)

or to contact ________________________________ (other parent/guardian)

at ______________ (phone number) have been unsuccessful, I give my consent for:

1. The administration of any treatment deemed necessary by _____________________ (preferred physician)

or ___________________________ (preferred dentist), or, in the event the appropriate preferred practitioner is not available, by another licensed physician or dentist; and

2. The transfer of the minor to ________________________ (preferred hospital) or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

The following information is needed by any hospital or practitioner not having access to the minor's medical history:

Allergies: ________________________________________

Medication being taken: __________________________________________________

Date of last tetanus shot: __________________________________________________

Physical impairments: ____________________________________________________

Other pertinent facts to which physician should be alerted: ______________________________

______________________________ (Signature)

______________________________ (Date)

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