Student Overnight Travel Emergency And Medication Form
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1STUDENT OVERNIGHT TRAVEL
EMERGENCY AND MEDICATION FORM
Date/Duration of Travel:_________________________
Student Name: __________________________________________________ Home Phone: ___________________________
Address:__________________________________________ City:__________________ State: ______ Zip: _____________
Father/Guardian Name: ___________________________ Work Phone: _________________ Cell Phone: ________________
Mother/Guardian Name: __________________________ Work Phone: _________________ Cell Phone: _________________
If I am unavailable in the event of an emergency, the following people may make decisions on my behalf and/or assume
temporary custody if necessary:
Local friend or relative
Relationship
Home Phone
Work Phone
Pager/Cell
Physician: ______________________________________ Phone: ________________ Hospital Preference: __________________________
•
Do you authorize a certified district employee or Principal’s designee to give your child acetaminophen (non-aspirin
substitute)?
Yes_____ No_____
•
Specify health problems/allergies_______________________________________________________________________
•
Is your child on daily medication? No_____ Yes_____ (If yes, complete consent for giving medication below.)
•
Limitation, concerns or other information: _______________________________________________________________
•
Insurance Carrier:_________________________ Group Number: ______________________
MEDICAL TREATMENT AUTHORIZATION:
In the event of illness or injury occurring to my child while on this travel/activity, I hereby give my consent for medical or dental care deemed
necessary by the attending health care provider or dentist. My child may be examined and any necessary procedures (medical, dental or
surgical), anesthesia, or diagnostic procedures (lab or x-ray) may be performed under the supervision of a member of the hospital or medical
office staff furnishing such services. I further acknowledge that I am financially responsible for any medical, dental, ambulance, or other
health care expenses or transportation of my child home, which might occur as a result of such illness or injury. I understand that Mesa Public
Schools does not provide accident medical/dental coverage for students for injuries/illnesses occurring during travel/activities. I also
acknowledge that I may obtain accident insurance through Risk Management if I do not currently have family medical insurance. I understand
that, in the event of other than minor illness or injury, reasonable effort will be made to contact me.
CONSENT FOR GIVING MEDICATION:
I hereby request and give my consent for a certified district employee or principal’s designee to see that my child receives the medication as
listed below:
DIAGNOSIS/
TIME TO BE
DATE
DATE
MEDICATION
DOCTOR
REASON FOR GIVING
GIVEN
FROM
TO
Prescription medication must be in the original container as prepared by a pharmacist and labeled, including the patient name, name of
medication, dosage and time to be given. Any over-the-counter medication must be in the original packaging with all directions, dosages,
compound contents and proportions clearly marked.
Signature of Parent/Guardian
____________________________________
Date___________________
JHCD-R-F(6) (Revised 07/01/12)
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