Mrs. Barbagelata's Permission Slip Copy

 

SHENENDEHOWA                    Field Trip Emergency Consent Form
      CENTRAL SCHOOLS                                    

I am aware that the __________________________________ will be traveling to _________________________ _________________ on ________________. My child has my permission to travel with this organization.

I, _________________________ (parent/guardian, please print), give permission to Shenendehowa staff or chaperones to act on my behalf for _______________________ (student name, please print), in the event of a medical emergency.
Date of Birth________________________________ Home Phone______________________________________
Father Daytime Number _______________________ Mother Daytime Number_____________________________
Family Physician ____________________________ Phone Number ____________________________________
Family Dentist ______________________________ Phone Number ____________________________________
Insurance Company __________________________ Policy Number ____________________________________
Insurance Address ___________________________ ________________________________________________
Name of Insured _____________________________ Employer ________________________________________
If parent or /guardian can't be reached, please contact:  
Name _____________________________________ Phone Number ____________________________________
Name _____________________________________ Phone Number ____________________________________


I hereby grant permission for Shenendehowa Central School District and its employees full authority to take whatever action they deem necessary regarding my child's health and safety in the event I cannot be reached or in a situation where time is of the essence; and fully release the Shenendehowa Central School District and it's employees from any liability in connection with those decisions. I grant permission for emergency treatment by a rescue squad, private physician and/or hospital or emergency health care facility staff if needed. Any such action will be taken in the best interests of my child and will be reported to me as soon as possible.

Please indicate if your child has: (Check all that apply and describe below)

Asthma ___________ Seizures __________ Last Tetanus (date)_______________ Other _______________
Severe Allergy ______ Diabetes __________ History of Surgery (describe) _______
Other Allergies _____ Special Diet ________ Physical Limitation_______________
 
 
 


Will medication be required during the field trip?    Yes _____    No _____
Describe _______________________________________________________________________
Students may not carry any medications (prescription and nonprescription) on a field trip. If medication is necessary, school personnel must carry the medication and dispense it to the student. Written instructions signed by the student's physician must be on file with the school. These instructions must include the diagnosis, name of medication, dosage, and time of administration. Medication must be in the original labeled container.

I grant permission for school personnel to administer medication to my child as prescribed by his/her physician. My signature gives permission for both the field trip and any necessary medical action.

_______________________________      __________________________
Parent Signature                                                                 Date

 

HRE2