Dayton Christian School System Emergency Medical Authorization Form Please use ballpoint pen to PRINT or TYPE. Pross firmly and complete ALL blanks. NAME OF CHILD. Birthdate, Devotional Teacher, ‘Grade ‘Schoo! Year 20, 20 NAMES OF PARENTS OR GUARDIANS. ert Home Address ‘Schoo! District city, Zip. Home Phone Father: Wk. Ext Cote Mail Moth, Wk Et. cot Ma [SeSsESEeEEESE SE EEEEEEEDTEE SIBLING'S AT DCSS: Names and grades ee Okto transport younger sibling's AUTHORIZED PERSONS to assume responsi ity for schoo! dismissal and provision of care when parent or guardian cannot be reached. PLEASE NOTE: fa 1 Phone Cet Relationship 2. Phone Cell Relationship 3 Phone Cel Relationship. 4. Phone. Catt _____ Relationship ‘Name for Emergency Contact Only fno other available contact can be mate within a reasonable time. 5. Phone Cell Relationship Family Physician or Pediatrician_ ee Phone, Famity Dentist Phone Local Hospital Preference Phone Insurance which applies to child Relevant medical factors, medications currently taking Physical impairments. Severe allergies Epipen Yes. No. Do allergies or asthma require medication at school? Yes No. | will send medication in "any medications or treatments are needed at school, please send approptata medal is and means to school. See Clinic staf if chic has allergies, dlabetes, asthma, seizures, or heslth concerns {CONSENT FOR EMERGENCY TRANSPORTATION AND MEDICAL TREATMENT: In tho event myfour child needs to be ‘ransported by ambulance or emergency vehicle, we authorize transportation, rar ae feazonabie attempts to contact me/us have been unsuccesst, Lie hereby ave my/our consent for admin ‘stration of any treatment deemed necessary by Dr. (preferred doctor) or Dr. (preferred dentist: or, in the event the designated practitioner 's not avalable, by another doctor or dentist, and the transfer of the chi to tho above stated hospital or any hospital reasonably sccessble, This authorization does not cover major surgery unless the medical opinions of two (2) other Heonces physicians or entists, concurring inthe necessity for such surgery, are obtained prior tothe porformance of ach surgery. ‘SIGNATURE OF PARENTS/GUARDIANS. Date Ceerepe er eeeeesee nsasaantnvanesni aos eeeeEESSay Date te | 2. REFUSAL OF CONSENT NOTE: Do NOT) ‘complete Part 2 if you have completed Part. iNWe do hot ‘give my/our consent | {or emorgoncy medica treatment or emergency transportation of myiour chi. n the event of finess on injury requiring ‘emergency treatment, (ve wish the school authorties to take no action, orto: ‘SIGNATURE OF PARENTS/GUARDIANS, Date. ate Date Bev. Gio