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Spec_Emergency-Medical-Authorization_pdf

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					                    Emergency Medical Authorization
Name_______________________________________________________________________________________

Date of birth_________________________________________________________________________________

Address _____________________________________________________________________________________

City _____________________________________________________ State ______ Zip __________________
In the event of an emergency,
I hereby give permission to ____________________________________________________________________
                                                                    (name of church)
____________________________________________________________________________________________
                                       (teacher’s name or other adult sponsor)
to obtain medical assistance for the above mentioned person. I also give permission to the physician select-
ed to hospitalize and secure proper treatment for
 ____________________________________________________________________________________________
                                          (myself or ward—son, daughter)
Insurance company __________________________________________________________________________

Address _____________________________________________________________________________________

Policy number _______________________________________________________________________________

My Social Security number ____________________________________________________________________

Parent(s) S.S. number_________________________________ _______________________________________
                                                       (if appropriate)

Numbers where caretakers or family ____________________________________________________________
can be reached: (Please give name, ______________________________________________________________
relationship, phone) __________________________________________________________________________

Allergies, medications, miscellaneous medical information _________________________________________

____________________________________________________________________________________________

My primary-care physician and phone number ___________________________________________________

Hospital preference (if in town) ________________________________________________________________

Signature of person __________________________________________________________________________

Signature of guardian (or parent) _______________________________________________________________

Date _______________________________________________________________________________________

*Check with your local agencies and/or a lawyer to determine if this form meets the requirements of your state laws.




                         E SSENTIALS    for E   XC E L L E N C E
                         CONNECTING SPECIAL EDUCATION
                         SUNDAY SCHOOL TO LIFE

				
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posted:5/17/2009
language:English
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