Medical Treatment Authorization

indicates a required answer

2025-2026 School Year

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.

NOTE: A separate form is required for each student.
1. *

Student's First and Last Name
2. *

Date of Birth
3. *

Gender
Male Female
4. *

Preferred Hospital
5. *

Allergies to medications

 

Authorization and Consent of Parent(s) or Legal Guardian(s)

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 it is given to provide authority and power on the part of the Designated Adult (Scholars 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.
6. *

Signature
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

 

Treatments Scholars Staff May Administer
7. *

Scholars may administer:

 (1 required)
Tums Antibiotic ointment and lotion
Bandaids Ibuprofen
Tylenol Benedryl
Use of contact solution No treatments may be administered
Other ______________________________________
8. *

I give my permission for Scholars to administer the above noted treatments to my student.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
9. *

Email address to receive a copy of this authorization
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