School Trip Consent Form/ Emergency Medical Treatment Form
1. Date of Event/Field Trip: _______________________________
Destination: _________________________________________
Date of Departure: ____________________________________
Date of return: _______________________________________
Mode of Transportation To & From Event: _______________________________________
Medical and Dietary Details of your child
Student Name: ___________________________________________ Grade: _______________________
Parent/Guardian Name: _____________________________________________________________________
Home Address: ____________________________________________________________________________
Phone: ______________________________________ Business Phone: _______________________________
Please list a person other than the parent or guardian who could be contacted in case of an emergency below:
Emergency Contact: ______________________________________ Phone # : __________________________
a. Any conditions requiring medical treatment, including medication? ________YES _______NO
(Please let us know of all such conditions, even if you have already notified the school).
If YES, please give brief details:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
b. Please outline any special dietary requirements of your child and the type of pain relief medication
your child may be given if necessary.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
c. To the best of your knowledge, has your child been in contact with any contagious or infectious diseases
or suffered from anything in the last four weeks that may be contagious or infectious? ____YES ____NO
If YES, please give brief details:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
d. Is your child allergic to any medication? _____YES _____NO
If YES, please specify:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
In case of serious illness or injury where immediate care is needed, the school or its representative has
my permission to contact the appropriate emergency medical service. The emergency medical service
has my consent to provide necessary treatment or transportation for my child. I then request that I be
notified of the situation. The undersigned will be responsible for emergency treatment cost.
In the case of an accident or illness where immediate treatment of my child is not indicated, but where
(s)he is unable to remain at the field trip, I request that the school contact me or my designee to
arrange transportation for my child. If the school is unable to contact me, I request the other person
listed on this form be contacted and requested to care for my child. I understand that I must notify the
school if there any changes in this health emergency information.
Parent/ Gurdian Signature: ____________________________________ Date: ___________________
