Emergency Medical Authorization Form

Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached. 
 
Please complete one form for each child you have at St. Helen School.

Student Information

Parent/Guardian Information



Relative or Childcare Provider

Name of relative or childcare provider that should be called when parent or guardian cannot be reached:

Consent for Medical Treatment

Consent *
I give consent for the following medical care providers and local hospital to be called:
Parent/Guardian Signature *
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