Penfield Central School District

Iroquois Central School District

MEDICAL TREAMENT FORM

2015 WASHINGTON DC– FIELD TRIP

Student Name:

Street: City: Zip:

TO WHOM IT MAY CONCERN: I, the undersigned, being the parent, legal next of kin, or legal guardian of , hereby authorize any necessary medical treatment for this person while participating in the 2015 Washington DC trip. I guarantee payment for services rendered.

MEDICAL INSURANCE CARRIER:

CONTRACT NUMBER:

HEALTH CONCERNS

1. Allergies: q Food (please state specifics): q Bee q Latex

q Medication q None q Other:

Do you carry Epinephrine? q Yes q No

2. Asthma: q Yes q No Do you carry an inhaler? q Yes q No

3. Diabetes: q Yes q No Attach instructions as needed.

4. Special medical problems. (If none, please state)

5. Does participant require medication that will or may need to be given during th e course of the field trip ? If so please make sure a Medication Authorization Form is completed .

(If none, please state “none”)

6. Family Physician or Healthcare Provider:

7. Office Address:

City: State: Zip: Phone:

8. Family Dentist:

Please print:

PARENT/GUARDIAN NAME:

PARENT (S) ADDRESS:

FATHER: PHONE – Home : Work : Cell:

MOTHER: PHONE – Home: Work: Cell:

My son/daughter has my permission to be a part of this trip.

It is understood that he/she will be subject to all rules, regulations, and supervision of the chaperones.

PARENT/GUARDIAN SIGNATURE:

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