Docstoc

field-trip-permission-medical

Document Sample
field-trip-permission-medical Powered By Docstoc
					           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
students.

       MEDICAL TREATMENT AUTHORIZATION FORM

Student Name_____________________Birth Date__________Homeroom____________
                                                                              (Teacher Name)
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

Allergies:________________________________________________________________


Existing Medical Condition_________________________________________________

Family Physician_____________________                        Phone Number___________

Emergency Contact___________________                         Phone Number___________

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:11/22/2011
language:English
pages:1