SALT LAKE LUTHERAN HIGH SCHOOL
4020 SOUTH 900 EAST
SALT LAKE CITY, UT 84124
801.266.6676
EMERGENCY MEDICAL AUTHORIZATION
Purpose: For parent/guardians to authorize emergency treatment for children who become ill or injured while under school authority,
when parents cannot be reach.
Student Name DOB Blood Type
Address City/State/Zip
Parent/Guardian Home Phone # Alternate #
Alternate Contact Home Phone # Alternate #
Physician’s Name Phone #
Dentist name Phone #
Hospital Name Location
Insurance Carrier Policy #
Allergies of any type:
Please list restrictions/physical impairments:
Current or recent Medical Problems:
List Medications Student is taking and amount
Student has permission to take Tylenol and/or Ibuprofen: Yes No Amount
Does Student wear glasses or contacts: Yes ____ No ____
Authorization for Treatment: In the event reasonable attempts to contact me, (parent/guardian) are unsuccessful, I (we), the
undersigned parent/legal guardians, do authorize any hospital, clinic, or licensed physician to treat my/our child and administer any x-
ray examination, anesthetic, or surgical diagnosis rendered under the general or special supervision of any member of the medical staff
of the hospital, clinic or office.
In the event the designated preferred practitioner is not available, we authorize in advance another licensed physician or dentist the
authority and power to render care in his/her best judgment and the transfer of the child to any hospital reasonably accessible. It is also
understood that every effort shall be made to contact the parent/legal guardian prior to rendering treatment to the patient, but that
treatment will not be withheld if the parent/guardian cannot be contacted. Permission is also granted for the school’s athletic trainer or
coach to provide emergency treatment to my/our child prior to his/her admission to any medical facility.
Signature of Parent/Guardian Date
(Do not complete if you signed Authorization for Treatment. above)
Refusal to Consent: I, (Parent/Guardian) DO NOT GIVE consent for
emergency medical treatment for my/our child in the event of any illness or injury requiring emergency medical
treatment. I wish the school authorities to take no action and to do the following:
Signature of Parent/Guardian Date