FIELD TRIP PERMISSION MEDICAL/FORM
Parent or Guardian:
The well being of your child is our concern as he/she travels to the Deere Wiman House,
Butterworth Center and Circa ‘21 in Moline and Rock Island, IL on Monday, December
1. In case of medical emergency, hospitals will not treat minor age children without
parental consent. Please read and complete the Medical Treatment Authorization form
below. The student may carry an inhaler. An adult will administer all other medicines.
Please return this signed waiver to the counseling office by November 6 or the first 150
MEDICAL TREATMENT AUTHORIZATION FORM
Student Name_____________________Birth Date__________Homeroom____________
To whom it may concern:
I, the undersigned parent or guardian of the above named student, authorize school
personnel to obtain emergency medical care in the event such care is necessary.
Permission is hereby granted to the licensed physician or accredited hospital and their
associates to treat the aforementioned minor child. I understand that every effort will be
made to contact me prior to treatment unless it would be a life-threatening situation.
Parent or Guardian Insurance Company
Relationship Policy Number
Home Phone Work Phone
Existing Medical Condition_________________________________________________
Family Physician_____________________ Phone Number___________
Emergency Contact___________________ Phone Number___________