Travel Consent/health Form With Medication Addendum To Travel Consent/health Form Page 2

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North East Independent School District
10333 Broadway – SAN ANTONIO, TEXAS 78217
Phone (210) 356-9244, Fax (210) 657-8677
CONFIDENTIAL
Department o
Travel Consent/Health Form
Department of
Health Services
STUDENT: __________________________________________ Date of Birth: _______________________________
Insurance Coverage:
Insurance Company _______________________________________ Policy Number______________________
Group Number ____________________ Name of policy holder ______________________________________
Insurance Coverage (Secondary):
Insurance Company _______________________________________ Policy Number______________________
Group Number ____________________ Name of policy holder ______________________________________
Dental Coverage:
Insurance Company _______________________________________ Policy Number______________________
Group Number ____________________ Name of policy holder ______________________________________
Health Related Information About Student:
List allergies to food, medications, other. If none, so state. ____________________________________________
___________________________________________________________________________________________
Special Health Concerns. If none, so state. ________________________________________________________
___________________________________________________________________________________________
Date of last Tetanus vaccine ____________
Name of student’s physician________________________________________ Office Phone________________________
Name of student’s dentist __________________________________________ Office Phone________________________
Parent/Guardian Name _______________________________________Relationship_____________________________
Phone Numbers: Home __________________ Work _________________Cell ________________ Pager _____________
Parent/Guardian Name _______________________________________Relationship_____________________________
Phone Numbers: Home __________________ Work _________________Cell ________________ Pager _____________
Alternate Adult Name _______________________________________Relationship______________________________
Phone Numbers: Home __________________ Work _________________Cell ________________ Pager _____________
Alternate Adult Name _______________________________________Relationship______________________________
Phone Numbers: Home __________________ Work _________________Cell ________________ Pager _____________
North East Independent School District does not assume any financial responsibility, but will arrange for emergency care.
By signing this form you are giving the appropriate school personnel authority to call EMS to transport and to obtain
emergency medical care.
_____________________________________________________
_________________________________
Parent/Guardian Signature
Date
7/14

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