Parental Consent And Student Medical Information For School Trips (Page 2 of 2) in pdf

Parental Consent And Student Medical Information For School Trips Page 2

Parent/Guardian Name __________________________________________ Day Phone (

) ____________________________

Home Address_________________________________________________ Evening Phone (

) _________________________

Emergency Contact_____________________________________________ Emergency Phone (

) ______________________

Name of Insurance Company_______________________________________

Policy #____________________________________

School Trip Health Information

In the event that the routine medical needs of any student attending the school trip cannot be met by school employees, a licensed

nurse may be required to attend. Parents of students with medical needs will be contacted directly by the assigned school nurse.

In the event of an accident or emergency, the below information may also be provided to emergency medical providers as needed.

Student has no medication(s) and/or needs no medical assistance during this school trip

Student requires medication(s) and/or medical assistance during this school trip (*complete information below)

Parent/Guardian will be attending the school trip and will provide medication(s) and/or medical assistance for this student

*List all daily and emergency medications (including dosage and time taken) that will be needed during this school trip

Medication

Dosage

Time

Does the student require medical assistance, other than the administration of medication(s)?

Yes

If yes, describe: _______________________________________________________________________________________

____________________________________________________________________________________________________

List all allergies:

____________________________________________________________________________________________________________

This form must be kept with school officials at all times during the school trip.

Page 2 of 2

1713-a

Revised 8/24/15

Parental Consent And Student Medical Information For School Trips Page 2