Student Travel / Emergency Medical Consent Form
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2Student Travel / Emergency Medical Consent Form
Student Name:
_____________________________________________________________
Type/Date of School Activity/Trip: _______________________________________________
To be completed by parent/guardian and copies kept on file in Principal’s Office prior to student travel.
PERMISSION / AGREEMENT
I hereby agree to allow my child ________________________to participate in the school activity/trip indicated
above. I acknowledge that my child is healthy and well enough to travel/participate in the above noted activity.
Your signature below indicates that you agree to the following conditions. I, the undersigned parent/guardian of
the above-named student:
agree for him/her to participate in this school trip.
hereby authorize the teacher(s) in charge of this trip to secure medical advice as may be deemed
necessary for the health and safety of my daughter/son/ward.
__________________________________
___________________________
SIGNATURE OF PARENT/GUARDIAN
DATE
STUDENT DATA
NAME:
______________________________________________________________________________________________________________
LAST NAME
FIRST
MIDDLE
______________________________________________________________________________________________________________
ADDRESS
CITY
PROVINCE
______________________________________________________________________________________________________________
POSTAL CODE
TELEPHONE
______________________________________________________________________________________________________________
BIRTH DATE DAY MONTH
YEAR
GRADE
MEDICAL INFORMATION
PLEASE SPECIFY ANY OF THE FOLLOWING:
ALLERGIES:
_____________________________________________________________________________________________________________
MEDICATIONS:
____________________________________________________________________________________________________________
DIETARY CONCERNS:
____________________________________________________________________________________________________________
OTHER:
___
___________________________________________________________________________________________________________
MCP#: ________________________________________________
MCP Expiry Date: _____________________
DOCTOR:
_____________________________________________________________________________________________________________
NAME
TELEPHONE
PARENT / GUARDIAN DATA
NAME:
_______________________________________________________________________________________________
LAST NAME
FIRST
RELATIONSHIP
TELEPHONE:
__________________________________________________________________________
HOME
WORK
ALTERNATE CONTACT DATA
CONTACT:
___________________________________________________________________________________________________________________
LAST NAME
FIRST
RELATIONSHIP
TELEPHONE:
HOME
WORK
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