Hermon-DeKalb Central School
DeKalb Junction, New York 13630
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Emergency Permission
PURPOSE: To enable parents to authorize emergency treatment for children who become ill or injured, when parents cannot be reached.
Child's Name _________________________________________ Date of Birth _________________
Address___________________________________________________________________________
In the event reasonable attempts to contact me at _________________ or _________________
(home phone) (business phone)
or ________________________________ have been unsuccessful, please contact:
(other parents' business phone)
Name Phone Number Relationship to Child
____________________ ____________ ________________
____________________ ____________ ________________
____________________ ____________ ________________
If those attempts have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by Dr. _____________________ or Dr. _____________________,
(Preferred Physician) (Preferred Dentist)
or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist.
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity of such surgery, are obtained before the surgery is performed.
Facts concerning the child's medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:
_____________________________________________________________________________
_____________________________________________________________________________
Date: ______________________ _________________________________________
Signature of Parent
Address
Appendix A