Microsoft Word - 09-10 PAGE 15 Nurse - Medical Release.docx
Georgia Military College Prep School
MEDICAL RELEASE FORM
AUTHORIZATION TO ADMINISTER MEDICAL TREATMENT
School Year 2009-10
I, , the parent, or guardian, or sponsor of,
(Print Name of Parent or Guardian or Sponsor’s Name) (Print Name of Student)
a minor child who is a commuting student at Georgia Military College Prep School, living with parent/guardian/sponsor, do hereby give:
My consent, that in the event all reasonable attempts by authorized school personnel to contact me have been unsuccessful, for the Principal of Georgia Military College Prep School, or his designated representative, to consent on my behalf to any x-ray examination, anesthetic, medical treatment, and hospital care of my minor child, as fully and effectively as if I were personally present.
I authorize the above-mentioned officials of Georgia Military College to serve in “loco parentis” for the transfer of an authorization of administration of any treatment deemed necessary for the treatment of my minor child.
I authorize the School Nurses of Georgia Military College to administer medications or treatments to my minor child according to the School Physician’s Standing Orders/Nurse Protocol.
I will be responsible for any medical or hospital fees or costs associated with the illness or treatment of this minor.
This authorization is granted pursuant to the provision of O.C.G.A. 31-9-2 (2) (4) of the Georgia Medical Consent Law.
Name of Student (Please Print) :
First MI Last
Signature of Parent, Guardian, or Sponsor
PERSON TO NOTIFY IN AN EMERGENCY SITUATION: (parent /guardian/other)
(1st Contact) Name
(2nd Contact) Name
First MI Last First MI Last
City State Zip City State Zip
Work Phone Cell Phone
Place of Employment Occupation
Place of Employment
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