Emergency Medical Authorization Form - PDF

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					                              Emergency Medical Authorization Form
                                         Perry Summer Camps


Please fill out the Emergency Medical Authorization Form (attached) and document if your child has any
health problems, allergies, or will be taking medication during camp. If your child has an allergy, please
have your physician document the prescribed treatment on the Statement of Physician Medication Form

The Statement of Physician Medication Form must be filled out for all medications given at camp. A
physician’s order and signature are required for all prescription medications. The Statement of Physician
Medication Form must also be filled out by a parent. No non-prescription medications will be given out at

An adult must deliver ALL medications in the original container to the camp director on the first day
of camp. Students are not allowed to carry medications to and from camp without a medical order.

Students are permitted to carry and self-administer inhalers; however, the Self-Medication Authorization
Form must be filled out and signed by the prescribing physician and parent and returned to the camp.

Please return the Emergency Medical Authorization Form and any necessary medication forms to:

                  Perry Community Fitness Center Summer Camps
                  One Success Blvd.
                  Perry, OH 44081

Please feel free to contact the CFC if you have any questions (259-9499).

Medical forms must accompany all registration form(s). Only one Emergency Medical Form,
Statement of Physician (if necessary) and Self-Medication Authorization Form (if necessary) are
required for each child.

Rev. April 2008
                                                     PERRY LOCAL SCHOOLS
Summer 2009                                              Emergency Medical Authorization Form
                                                               Revised Code §3313.712
Address:                                                                                      Date of Birth:
City, State, Zip
Telephone:                                                                                    Has your child ever been stung by a bee? ___________
Food Allergies: __________________________________________________                             (Please explain any reaction he/she may have gotten)______________
(Please list all)
                        __________________________________________________                     ___________________________________________________________

Purpose—To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured under school/PARB authority,
parents or guardians cannot be reached.

Residential Parent or Guardian

Mother’s Name:
                                First                                   Last
Home Address:                                                                                        Home Telephone:
                                                                                                     Cell Phone:
Work Address:                                                                                        Work Telephone:

Father’s Name:
                                First                                   Last
Home Address:                                                                                        Home Telephone:
                                                                                                     Cell Phone:
Work Address:                                                                                        Work Telephone:

Other Contact Name:
                                First                                   Last
Home Address:                                                                                        Home Telephone:
                                                                                                     Cell Phone:
Work Address:                                                                                        Work Telephone:


I hereby give consent for the following medical care providers and local hospital to be called:

Physician:                                                                                           Telephone:

Dentist:                                                                                             Telephone:

Medical Specialist:                                                                                  Telephone:

Local Hospital:                                                                                 Emergency Room Telephone:

    In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for [1] the administration of treatment deemed necessary by th
above-named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and [2] the transfer of the child
hospital reasonably accessible.
    This authorization does not cover major surgery unless the medical options of two other licensed physicians or dentists, concur in the necessity for such surgery
obtained prior to the performance of such surgery.
****                Facts concerning the child’s medical history, including allergies, medications being taken and any physical impairment which a physician should b

_______________________                                 ______________________________________________________________________________

Rev. April 2008
Date                                          Signature of Parent/Guardian

                                                        Statement Of Physician.
                                    For Medication to be Administered by School or PARB Employees
                                                      All Blanks Must Be Filled In

Name of Student:__________________________________________________ Allergies:____________________________________________

Name of Medication:___________________________________________________________________________________________________

Dosage to be Administered:______________________________________________________________________________________________

Time or Intervals Medication is to be administered:_________________________________________________________________________

Date Medication is to begin:____________________________________ Date Medication is to end:__________________________________

Any severe reactions that should be reported:______________________________________________________________________________

Special instructions for administration:___________________________________________________________________________________

Number where physician can be reached:________________________________

Name of Physician:____________________________________________ Diagnosis:_______________________________________________

Address of Physician:_______________________________________________________________ Date:_______________________________

Physician Signature:____________________________________________________________________________________________________

I hereby request and give consent that the medication described be administered by a school or PARB employee who has been duly authorized by the
Board of Education and/or the PARB Board to administer medications to students. I further agree that any employee administering the medication
described on the statement of the prescribing physician shall be entitled to rely upon the information therein contained in this statement. I further
specifically agree that if any information on the above statement changes that I will immediately notify the school or PARB and/or provide a revised
statement from the physician.


Signature of the parent/guardian:_________________________________________________________________________________

Name of the medication:_________________________________________________________________________________________

Daytime phone number:_________________________________________________________________________________________

Rev. April 2008