EMERGENCY INFORMATION CARD

Name *

Medicaid Number *

Address *

Social Security Number *

Telephone Number *

The following is required by section 3313.712 of the Ohio Revised Code.

EMERGENCY MEDICAL AUTHORIZATION

Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while

Under school authority, when parents or guardians cannot be reached.

PART I OR PART II MUST BE COMPLETED

ALL BLANKS MUST BE COMPLETED

PART I (TO GRANT CONSENT)

FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS BEING TAKEN, AND ANY PHYSICAL IMPAIRMENTS to which a physician should be alerted: *

Signature of Parent/ Guardian *

clear

Date * +

DO NOT COMPLTE PART II IF YOU COMPLETED PART I

PART II (REFUSAL TO GRANT CONSENT)

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to TAKE NO ACTION OR TO:

Signature of Parent/ Guardian *

clear

Date * +

1808 E. Broad St. l Columbus, Ohio 43203 l Phone: 614-545-9890 l Fax: 614-545-9889