Medical Release & Emergency Treatment Authorization

Official school form

Authorizes staff to seek emergency medical care for your child and lists the people we may contact when you cannot be reached.

Purpose

This form authorizes Solomon Heights Academy staff to obtain emergency medical care for the student named below in the event of illness or injury during school hours, on school grounds at 3200 NW 48th Street, Oklahoma City, Oklahoma 73112, or during any school-sponsored activity or field trip.

Authorization

I authorize the school to administer basic first aid and, if I cannot be reached, to call 911 and consent to examination, anesthesia, medical or surgical diagnosis, and treatment by a licensed physician, dentist, or hospital.

I understand the school will make every reasonable effort to contact me and the emergency contacts listed before treatment is sought, except where delay would endanger the student.

I accept financial responsibility for any medical care, transport, or treatment rendered. The school does not provide medical insurance for students.

Term

This authorization remains in effect for the current school year unless revoked in writing and delivered to the school office.

Information to complete

Student full name *

Student date of birth *

Parent / guardian name *

Parent / guardian phone *

Emergency contact 1 — name, relationship, phone *

Emergency contact 2 — name, relationship, phone

Preferred physician & phone

Preferred hospital

Health insurance carrier & policy number

Allergies (food, medication, environmental)

Chronic conditions, diagnoses, or special needs

I authorize school-administered over-the-counter first aid (bandages, antiseptic, cold pack).

Yes

I certify that the information above is accurate and I authorize emergency medical treatment as described.

Parent / guardian signature

Date

Solomon Heights Academy3200 NW 48th Street, Oklahoma City, Oklahoma 73112Medical Release & Emergency Treatment Authorization

Return completed forms to the school office at 3200 NW 48th Street, Oklahoma City, Oklahoma 73112.