Consent for Emergency/Medical Treatment

Print the Medication / Indemnification Form if your child needs to administer his/her own medication in the office.

Consent for Medical/Emergency Treatment

I/we, the undersigned parent(s)/guardian of (student name listed below), a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may so arise, or any hospitalization necessary.
Student Name*
First Last
Parent/Guardian Name*
First Last
Parent/Guardian Signature*
Medical Matter
Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
My child is taking medication at present. I will bring all such medications necessary, and such medications will comply with specific requirements on a separate form : “SJHS Medication / Indemnification Form” that has been completed. My child will administer his/her own medication in the office.
Parent/Guardian Signature
No medication of any type may be administered to my child unless the situation is life-threatening and emergency treatment is required.
Parent/Guardian Signature
This consent form will remain in effect until through the last day of school June 2020 for the care and treatment necessary to preserve the health of our/my child. We/I acknowledge that we are/ I am responsible for all reasonable charges in connection with care and treatment rendered during this period.
List current medicines your child is taking:
Any known allergies?
- Yes
- No
Explain and identify treatment
Any physical limitations?
- Yes
- No
Explain Physical Limitations
Student Emergency Information
Student info*
Click the + icon on the right to add additional children
First Name Last Name Grade Date of birth (mm/dd/yyyy)
Home Address*
Street Address Address Line 2 City State ZIP Code
Known allergies
Parish/Church/Other
Parents Info*
First Name Last Name # to receive school messages  (emergencies, weather, etc.) Employer / Company Home Phone (xxx-xxx-xxxx) Work Phone (xxx-xxx-xxxx) Cell Phone (xxx-xxx-xxxx)
Emergency Contact*
First Name Last Name Relationship Phone #

First Name	Last Name	Grade	Date of birth (mm/dd/yyyy)

First Name	Last Name	# to receive school messages  (emergencies, weather, etc.)	Employer / Company	Home Phone (xxx-xxx-xxxx)	Work Phone (xxx-xxx-xxxx)	Cell Phone (xxx-xxx-xxxx)

First Name	Last Name	Relationship	Phone #

Consent for Medical/Emergency Treatment

Medical Matter

Student Emergency Information

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