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: ________________________________________________

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