EMERGENCY MEDICAL TREATMENT FORM

EMERGENCY MEDICAL TREATMENT FORM

FOR OVERNIGHT FIELDTRIPS

The purpose of this form is to provide students with any emergency medical treatment that may be necessary while they are on an overnight Field Trip, since there will be no medical personnel on the trip. Parents may, at their discretion, provide pertinent medical history and/or authorization for emergency medical treatment with this form.

Student's Name _____________________________________________________________

Address _______________________________ Town ______________________________

Home Phone: ___________________________ Date of Birth ________________________

Pertinent medical history or conditions/allergies:

______________________________________________________________________________

If the student is currently taking medications, please list the drugs, strength and dosage:

_______________________________ Dosage ______________________________________

_______________________________ Dosage_______________________________________

In case of emergency, who may we call if no one is at the student’s home?

____________________________________ Telephone No. _____________________________

Treatment Authorization

I do hereby give permission for ______________________________________________to

authorize emergency medical care for my daughter/son

____________________________________ on the advice of qualified physicians if the parents

(student’s name)

can not be reached or if phone authorization is not accepted by an attending hospital.

____________________________________/ _________________________________________

Signature of parent or guardian Relationship to student

Medical Coverage Plan/Policy Number ______________________________________________