St. John Vianney Parish School of Religion 2022-23 Emergency Medical Authorization Purpose: To enable parents/guardians to authorize emergency treatment for children who become ill or injured while under school authority, when parents/guardians cannot be reached. STUDENT'S LAST NAME * STUDENT'S FIRST NAME * GRADE 2022-2023 * 1 2 3 4 5 6 7 8 Kindergarten ALLERGIES (if any) MEDICATIONS BEING TAKEN (if any) PHYSICAL IMPAIRMENTS (if any) Part I or Part II must be completed. You must provide the Email Address of the Parent/Guardian to receive a confirmation email after you submit this form. Part I (TO GRANT CONSENT) In the event that reasonable attempts to contact me at (Phone Number) Phone Number or other parent/guardian at (Phone Number) Other Phone Number have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by (Preferred Doctor) Doctor's Name at (Doctor's Phone Number) Doctor's Phone Number or (Preferred Dentist) Dentist's Name at (Dentist's Phone Number) Dentist's Phone Number or in the event the designated preferred practitioner is not available, by another licensed Physician or dentist; and (2) the transfer of the child to (Preferred Hospital) or any reasonably accessible hospital. Hospital Name This authorization does not cover any major surgery unless the medical opinions of two (2) other licensed physicians or dentists concur in the necessity for such surgery and concurrence is obtained before the surgery is performed. Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: Alert Doctors about these Medical Facts Parent/Guardian Name First Name & Last Name Address Address, Street, City and Zip Code Email Address of Parent/Guardian * Type your full Name in the box below to Grant Consent for Treatment Date Part II (REFUSAL TO CONSENT) -- DO NOT complete Part II if you completed Part I I do NOT give my consent for emergency medical treatment of my child. In the event of illness or emergency treatment being required, I wish the school authorities to take no action or to: Parent/Guardian Name First Name & Last Name Address Address, Street, City and Zip Code Email Address of Parent/Guardian * Phone Number Type your full Name in the box below to REFUSE to consent Date To submit this form: Check - I’m not a robot and complete the task. A green check will appear when completed correctly. Next click Submit. Wait to see the message that your responses will be sent to the SJV Faith Formation Office. reCAPTCHA If you are human, leave this field blank. Δ To complete this form for another child, Click here to leave this page the click the Emergency Medical Form link to return to this form.