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
Vol. 10 •Issue 3 • Page 32 Wound Care Evaluation & Management of Lower Extremity Ulcers Adherence to Prescribed Therapy Can Save Limbs By Susie Seaman, NP Lower extremity ulcers may affect up to 2.5 million people in the United States and are a source of significant morbidity and expense.1 Most leg ulcers are a result of chronic venous insufficiency, peripheral arterial d
TRANSFERS MORNING TRANSFER Your clients will be met at the airport by our staff and transferred to their hotel by our driver and guide. Service from 8 am. to 6 pm. NIGHT TRANSFER Your clients will be met at the airport by our staff and transferred to their hotel by our driver and guide. Service from 6 pm. to 8 am. SIGHTSEEING TOURS CITY TOUR – Mornings or Afternoons except Sunda