1.Grade:

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Student's Name 2a.First: 2b.Last:

3.Date of Birth

Phones: 5.Home:

6.Cell Mother/Guardian:

7.Cell Father:

First	Second
10. Mother Father Guardian	15. Mother Father Guardian Selection Off
11. Company:	16. Company:
12. Address:	17. Address:
13. City/State/Zip:	18. City/State/Zip:
14.Phone:	19.Phone:
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28.Signature Name: 29.Initials:

AUTHORIZATION FOR EMERGENCY TREATMENT OF MINOR

The undersigned is the parent/legal guardian of the minor identified. This authorization is being provided to the Emergency Services Department for use in the event of the need for emergency treatment of the minor identified when neither the undersigned, the family physician nor the relative or friend listed can be reached to provide consent to treatment. By electronically signing below, the undersigned hereby authorizes Physicians of the Emergency Services Department to perform on the minor identified, such emergency treatment or procedures as deemed appropriate, provided, however, that my consent or the consent of the family physician, friend or relative identified will first be sought unless the delay, in the opinion of the physician, is imprudent under the circumstances.

31.Health/Hospitalization Insurance:

32.Insurer:

33.Policy Number:

34.Initials:

35.

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MEDICAL HISTORY

INFORMATION PERTAINS TO ALL STUDENTS

May the nurse administer:

40.Aspirin? Yes No

41.Tylenol? Yes No

42.Ibuprofen (generic Advil)? Yes No

43.Initials:

44.

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