Emergency Medical Form

Emergency Medical Authorizations
This form must be completed on a yearly basis and updated throughout the year as contact information changes.
The top portion of this form provides us with information to update your child’s address in our computer system. 

Non-Resident Parent Information
Contact Info
The information in the section allows us to contact you during the day and is utilized as a list of persons eligible to pick up your student in case of illness or injury.
PART 1-Consent for Treatment
This portion allows access to your doctor and dentist during an emergency.
Medical Information
This portion allows emergency services and pertinent school personnel to be aware of child’s medical background.
This section is signed to enable emergency services to provide care if the parents are unable to be contacted.
PART 2-Refusal of Consent
This part is utilized by signing when consent is not given for medical treatment.
Northern Local School District
8700 Sheridan Road NW
Thornville, OH 43076

Phone: (740) 743-1303
Fax: (740) 743-3301