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Student permission slip and medical authorization form

Student Permission Slip and Medical Authorization Form

As parent(s)/guardian(s) of the above student, permission to granted for this student to
attend the [SCHOOL NAME/GROUP NAME]’s trip to [LOCATION] during the dates of
[DATES OF TRIP]. I/We am/are aware that the [SCHOOL NAME/GROUP NAME]
requires all participants on a trip to supply the following information in case a medical
emergency should arise during the trip.
1.) Insurance: Name of Insurance Carrier: __________________________________________ Group/Policy Number: ______________________________________________ 2.) Family Physician: Name:________________________ Phone Number: ( ) -___________Address: _________________________________________________________ ________________________________________________________________ 3.) Emergency Contact: If group chaperones/organizers are unable to contact you or any of the people listed as emergency contacts, they have the permission to make the necessary arrangements in an emergency to no expense to the organization. Please list emergency contacts below: Name: __________________________ Phone Number : ( ) -_________ Relationship: _____________________________________________________Name: __________________________ Phone Number : ( ) -________ Relationship: ____________________________________________________ Name: __________________________ Phone Number : ( ) -_______ Relationship: ____________________________________________________ 4.) Drug Sensitivities/Allergies:________________________________________ ________________________________________________________________ ________________________________________________________________ 5.) Medical Conditions/Medical Concerns: ______________________________ ________________________________________________________________ ________________________________________________________________ 6.) Date of Last Tetanus Shot: _______________________________________ 7.) Medications: ___________________________________________________ ________________________________________________________________ Time_____________ Dosage ___________________ Prescriptions: Time ____________ Dosage ___________________ Parent is responsible for assuring all medications, prescriptions or non- prescription items is supplied and accompanied by a written note specifying the medication dosage and then time it is to be given. All medications must be provided in its original container or package and marked with student’s name. MEDICAL AUTHORIZATION AND CONSENT: In the event of an emergency with would require medical care and treatment to be administered to the student, I/We hereby authorize any physician, hospital, school nurse, athletic trainer, or other health care provider to give medical care and treatment to this student. The undersigned have read the Trip and Medical Authorization Consent Form and declare and affirm that I/We consent to the contents herin stated. Parent/Guardian

Source: http://www.epntravel.com/pdf/StudentPermissionSlipandMedicalAuthorizationForm.pdf