Emergency Medical Consent-WV Academy, Ltd.

Emergency Medical Consent

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I authorize West Virginia Academy, or the assigned designee, to provide emergency treatment for my child if they become ill or injured while under school authority and when parents cannot be reached. I grant consent when in the event reasonable attempts to contact me at the above numbers. I hereby give my consent for the administration of any treatment deemed necessary by my personal doctor or my preferred dentist. If either of my designated preferred providers are not available, then by another licensed physician or dentist. I also hereby authorize the transfer of my child to my preferred hospital or any hospital reasonably accessible. NOTE: This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring on the necessity for such surgery, are obtained prior to the performance of such surgery.

I give my consent for emergency treatment of my child in the event of illness or injury requiring emergency treatment.

Student's First Name

Student's Last Name

Address

Phone Number

Preferred Doctor

Preferred Doctor's Phone Number

Preferred Dentist

Preferred Dentist's Phone Number

Preferred Hospital

Your Signature