Marshall School District
(Bueker Middle School)
Trip
Approval & Emergency Medical Authorization
Student:__________________________________________________
Teacher:__________________________________________________
Destination:________________________________________________
Date of Trip: _________
I, the undersigned
parent/guardian, do give my permission for the above-named student to attend
the field trip of date. I also give my permission for authorized school personnel
to seek and obtain emergency medical treatment if they deem necessary.
The school, authorized person, or medical treatment facility will make every
reasonable attempt to notify the parent/guardian prior to such treatment.
If contact is unsuccessful, then emergency treatment can proceed.
Parent/Guardian:__________________________Date:________________
Home Phone: __________________
Work Phone:_______________
Alternate Person:
_______________ Alternate Phone:_____________
Medical Insurance
Company:________________________________
Is your child allergic to any medication(s)? _____yes ______no
If yes, please explain_______________________________________
Will your child
need to take medication while on field trips? __yes___no
If yes, please explain_______________________________________
Does the school
nurse have this medication to send on the field trip?__yes___no
If there is any additional information that needs to be taken on field trips please call Mrs. Green, School Nurse at 886-6833.
Other information:
______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Parent/Guardian
Signature: _______________________________________________________