Parent'S Or Guardian'S Authorization For Pupil'S Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form printable pdf download

Parent’s or Guardian’s Authorization for Pupil’s Participation in Board of Education

Approved Overnight Trip Health History and Release of Claims

STUDENT INFORMATION

Student’s Name: ___________________________________

DOB: ______________ Age: ________

Student’s Address: _________________________________

Home Phone #: __________________

Full Name of Parent/Guardian: ___________________________________________________________

Parents’ Cell #s: (1) _________________________________

(2) ______________________________

Parent’s Work #: ____________________________

Student Cell #: ___________________________

Parent’s Email Address: _________________________________________________________________

HEALTH HISTORY

Does Student Have: Medical Insurance? Yes ___ No ___ Prescription Plan? Yes ___ No ___

Name of Insurance Company:

_________________________ Insurance Policy #: _________________

Name of Prescription Plan: _____________________________

ID #:_____________________________

Physician’s Name: ____________________________________

Phone #: _________________________

HEALTH HISTORY:

ALLERGIES:

Please indicate date/s and describe below.

Please provide additional information below.

_____ Concussion/head injury

_____ Insect/bee sting allergy. Describe reaction.

_____ Diabetes

_____ Food allergies. Please specify.

_____ Asthma

_____ Medication allergies. Please specify.

_____ Epilepsy/seizures

_____ Other allergies. Please specify.

_____ Cardiac problems

________________________________________

_____ Surgery (within 1 year)

________________________________________

_______________________________________________________________________________________

Current health concerns: ___________________________________________________________________

________________________________________________________________________________________

Date of student’s last tetanus shot: ___________________________________________________________

MEDICATION

Students are prohibted from carrying or self‐administering any medication whether it’s prescribed or over the counter

while participating on a school sponsored trip as per BOE Policy #5330. All such medication must be carried and

administered by a Board approved licensed nurse. However, New Jersey law povides that students are permitted to

self‐administer medication only “for asthma or other potentially life‐threatening illnesses or a life‐threatening allergic

reaction” N.J.S.A. 18A:40‐12.5 (i.e. epi‐pens or inhalers). The parent/guardian of the student must provide the school

nurse with a written authorization from the student’s physician and together develop an individualized healthcare plan.

Therefore, a student may only mediate self under these limited conditions.

Parent'S Or Guardian'S Authorization For Pupil'S Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form

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