Trip Health Form 2018

Student Name  _______________________________________  Grade __________

Address ______________________________________________________

Parent/Guardian Phone Number: (home) ____________ (work) __________________

Parent/Guardian Phone Number: (home) ____________(work)  __________________

Emergency:Name ________________________   Relationship ___________________

   

Telephone ____________________

                           

Family Doctor:    Name ________________________   

Telephone ____________________

Insurance Name________________   Insurance#____________________

                           

1.  Important illness(es), disabilities, or activity restrictions of which we should be aware:

________________________________________________________________________

2.  Is your child allergic to plants, insect bites, poison ivy, etc. (be specific)?

________________________________________________________________________

3.  Is your child allergic to drugs or food (be specific)?

________________________________________________________________________

4.  Is your child permitted to have Tylenol ______  Ibuprofen ______ Benadryl ______ ?

5.  Is your child bringing any medications on the trip?  (Medication must come from home, not nurse.) ________________________________________________________________________

6.  What are the instructions for taking the medications?

________________________________________________________________________

________________________________________________________________________

I give permission to the supervising faculty to secure treatment for my child in the event of illness or injury.  If I cannot be reached, I give permission to the physician selected by the faculty to order treatment if necessary.

Parent Signature __________________________________________________________

Date ________________