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.

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.


Phone Number
Other Phone Number
Doctor's Name
Doctor's Phone Number
Dentist's Name
Dentist's Phone Number
Hospital Name
Alert Doctors about these Medical Facts
First Name & Last Name
Address, Street, City and Zip Code

Part II (REFUSAL TO CONSENT) -- DO NOT complete Part II if you completed Part I

First Name & Last Name
Address, Street, City and Zip Code

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.


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.