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: _____________________________________________________
Does your child have any health/medical concerns? ______yes
______no
If yes, please explain ____________________________________________________________________________
Does your child take medication? ______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: ________________________________________________