Medical Authorization

This form grants temporary authority to a designated adult with Scholars to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them.

Student Name

First Name

Last Name

Date of Birth

Gender

Male

Female

Parent/Guardian to contact in emergency

First Name

Last Name

Phone

(###)

###

####

First Name

Last Name

Phone

(###)

###

####

Emergency Contact

Provide the contact information of an authorized individual who may pick-up your child from Scholars or assist in managing your student's needs during an emergency situation should you be unreachable.

First Name

Last Name

Relationship to student

Emergency Contact Phone Number

(###)

###

####

Student Medical Information

Medical Concerns

List any medical or health concerns that the teachers and/or Admin Team at Scholars need to be aware of. Comment N/A if this does not apply.

Allergies

List any known allergies for your student. Comment N/A if this does not apply.

Medication

List prescription medication (and current dosage) your student will need to take during the school day at Scholars. The Admin Team will keep all medication secured and will dispense it accordingly. Comment N/A if this does not apply.

Over the counter medications used at Scholars

Check which medications/treatments you allow Scholars to administer to your student when necessary. Whenever medications are distributed, parents are promptly informed via email notification.

NO MEDICATIONS/TREATMENTS MAY BE ADMINISTERED

Antibiotic ointment (Neosporin)

Ibuprofen

Tylenol

Tums

Cough drops

Benadryl

Parent/Guardian consent for student's medication/treatment

My typed name acts as an electronic signature giving Scholars permission to administer the checked medications/treatments listed above. If you chose no medications/treatments, please make sure that box is checked and type your name below.

Date

YYYY

Parental/Guardian consent and authorization

My typed name below serves as an electronic signature that I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for Scholars faculty/staff to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated adult (Scholars faculty/staff) to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Designated Adult (TSC faculty/staff) in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. Authorization is effective for the entire school year.

Date

YYYY