Download 3. Emergency Medical Authorization

Ola Academy
Early Learning & Child Care 2773 Highway 81 East, McDonough, Georgia 30252
Emergency Medical Authorization
Should ________________________________, _____________________ suffer an injury
[Child’s name]
[Date of Birth]
or illness while in the care of Ola Academy and the facility is unable to contact me (us)
immediately, it shall be authorized to secure such medical attention and care for the child as
may be necessary.
I (We) agree to keep the facility informed of changes in telephone
numbers, etc. where I can be reached.
Ola Academy agrees to keep me informed of any incidents requiring professional
medical attention involving my child.
Child’s primary source of health care is:
____________________________________
Telephone Number:
________________________________
[Physician/Clinic Name]
_______________________________________________________________________
[Address]
Known medical conditions (i.e. diabetic, asthmatic, drug allergies):
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________
Does your child have any other type of allergies we should be aware of? (i.e. any type of
food such as milk or peanuts, synthetic materials, etc.)
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
_________________________________
Signature (Parent/Guardian)
Telephone Number ___________________
_____________
Date