Medical Treatment Authorization and Emergency Consent Form

Troy USD 429

Medical Treatment Authorization and Emergency Consent Form

The following form is designed for those situations where minors are unaccompanied by either parent or legal guardian. This form gives authority to a designated adult to arrange for medical care for the minor in the even of an emergency. This is extremely important, in that, medical care cannot be provided to a minor without approval by the parents or legal guardians, unless there is written consent providing approval.

Student's Name*

First Name

Last Name

Attending School *

Date of Birth

USD 429 has on file a copy of a signed Medical Treatment Authorization and Emergency Consent Document. *

My 2022-2023 Information has not changed and I consent Troy USD 429 does not have my current Medical Treatment Authorization Form on file.

Allergies *

Permission is hereby granted in the event of a serious illness/injury to proceed with any medical treatment. I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. If said physician is not able to communicate with me, the treatment necessary for the best interest of the student may be given.

Parent/Guardian Signature *

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Date*

Phone*

Name of Family Physician *

Physician Phone

EMERGENCY CONTACT INFORMATION

Name*

First Name

Last Name

Phone*

Name*

First Name

Last Name

Phone*

RELEASE AND INDEMNITY AGREEMENT

Click here to open the Release and Indemnity Information

By signing this document, the undersigned acknowledges and states:

• Is over 18 years of age and is a parent/legal guardian of the abovenamed student

• Gives permission to provide medical treatment if necessary

• Understands the legal significance of above document and has voluntarily signed this document

Date

Printed Name of Parent/Legal Guardian *

First Name

Last Name

Signature of Parent/Legal Guardian*

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