REACH Medical Authorization Form

myUS

REACH Medical Authorization Form

In the event of a child’s serious illness or accident occurring while he is at the REACH Program (hereinafter "REACH") or elsewhere under REACH supervision, the policy of REACH is to first notify the student’s parent/guardian, then his physician, as designated below, as soon as reasonably possible. However, if REACH is unable to locate such designees and considers immediate treatment necessary, then I, the undersigned parent/guardian, hereby authorize REACH to take such emergency measures as seem reasonably necessary under the circumstances, including treatment and/or surgery by an available physician and/or in a nearby hospital.

*Student Name

*Your Name

*Your relationship to student

*Your Email

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*Student's Date of Birth

*Student Entering Grade

*School student will attend in the fall

*Public School District where student resides

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*Student Address Street

*Student Address City

*Student Address State

*Student Address Zip

*Student Phone

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Salutation of Father or Guardian

First Name of Father or Guardian

Last Name of Father or Guardian

*Does Father or Guardian live with the student?

Address of Father or Guardian

Father or Guardian Address Street

Father or Guardian Address City

Father or Guardian Address State

Father or Guardian Address Zip

Father or Guardian Place of Employment

Father or Guardian Work Phone

Father or Guardian Cell Phone

Father or Guardian Preferred Email

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Salutation of Mother or Guardian

First Name of Mother or Guardian

Last Name of Mother or Guardian

Does Mother or Guardian live with the student?

Address of Mother or Guardian

Mother of Guardian Address Street

Mother or Guardian City

Mother or Guardian State

Mother or Guardian Zip

Mother or Guardian Place of Employment

Mother or Guardian Work Phone

Mother or Guardian Cell Phone

Mother or Guardian Preferred Email

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If student does not live with Father, Mother or Guardian, please list name and relationship

US would like you to list 2 emergency contacts other than parent(s) or guardian(s).

Emergency Contact 1 Name

Emergency Contact 1 Relationship

Emergency Contact 1 Cell Phone

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Cell Phone

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Physician's Name

Physician's Phone Number

Preferred Hospital

Hospital Emergency Room Phone

Medical Insurance Provider

Medical Policy Number/Type

Dentist's Name

Dentist's Phone Number

Dental Insurance Provider

Dental Policy Number/Type

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Are immunizations up to date?

Date of Last Tetanus

Injuries/illnesses/operations in the past year

Conditions for which student is currently under treatment or supervision

Name/dosage of prescribed medications to be given at home

Name/dosage of prescribed medications to be given at REACH

Allergies (include medications, foods, inhalants, stinging insects, etc.)

Please note: If medication is to be given at REACH, a current doctor's order and parent authorization must be submitted. Medication must be provided in its properly labeled prescription bottle.

Restrictions in physical activity

Additional information the Director should know about (please be specific)

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By clicking Submit, you agree to all terms stated in this Emergency Medical Authorization Form.

Click the Submit button for the form to be sent to REACH. Please close the window or tab to continue registration. Thank You.

Your Name

Shaker Heights Campus

20701 Brantley Road
Shaker Heights, Ohio 44122
JUNIOR K – GRADE 8
Phone: 216-321-8260

Hunting Valley Campus

2785 SOM Center Road
Hunting Valley, Ohio 44022
GRADES 9 – 12
Phone: 216-831-2200

University School serves over 850 boys in Junior Kindergarten to Grade 12 on two campuses in suburban Cleveland, Ohio. The School’s mission is to inspire boys of promise to become young men of character who lead and serve. Dedicated faculty, rigorous curriculum, and experiential programs foster intellectual, physical, creative, and moral excellence. University School is a diverse and inclusive community where each boy is known and loved.