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Form #717Authorization to School
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Authorization to School - Emergency Medical Treatment for Minor (Free Legal Form)
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AUTHORIZATION
TO SCHOOL
 EMERGENCY
MEDICAL TREATMENT FOR MINOR
Authorization
Â
I, ______________________, of
__________________________________________ (address), am the
______________________ (father/mother/legal guardian) of
______________________, a minor, of _____________________________________
(address), who attends ____________________________________ (name of school),
located at ____________________________________________________ (address).
Â
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:
Â
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
Â
2. The transfer of the minor to
________________________ (preferred hospital) or any hospital reasonably
accessible.
Â
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.
Â
The following information is needed
by any hospital or practitioner not having access to the minor's medical
history:
Â
Allergies:
______________________________________________________________
Â
Medication being taken:
__________________________________________________
Â
Date of last tetanus shot:
__________________________________________________
Â
Physical impairments:
____________________________________________________
Other pertinent facts to which
physician should be alerted: ______________________________________________________________________
______________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __________________________
(Signature)Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â (Date)
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Keywords: legal forms, family, minor, emergency, medical treatment
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