Form 119 - Medical Release Form-Lcps Out-Of-State Trips - 1998

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MEDICAL RELEASE FORM-LCPS OUT-OF-STATE TRIPS
A Doctor’s Certificate is NOT required. (This form is to be completed by parent/guardian-regardless of your age)
STUDENT NAME:_______________________________________________ AGE:______ D.O.B.______________
SS#:_______________________________
Student taking any medication? YES______ NO ______ If yes, list below:
Immunization History: (Give date of most recent booster dosage)
DPT _________________ Tetanus _________________ Small Pox _________________ Polio _________________
Measles ______________ Mumps _________________ Any other________________________________________
Does student get motion sickness? YES ________ NO ________
If yes, provide Dramamine, etc. and list dosage to be taken _______________________________________________
———————————————————————————————————————————————
Does student have any dietary restrictions or considerations that we need to be aware of: (Religious, allergies,
vegetarian, etc.):_________________________________________________________________________________
———————————————————————————————————————————————
MEDICAL INSURANCE COMPANY COVERING STUDENT:__________________________________________
POLICY NUMBER:_________________________________________ GROUP: ____________________________
PRIMARY INSURED MEMBER’S NAME:__________________________________________________________
EMPLOYER OF PRIMARY INSURED MEMBER:____________________________________
PHONE NUMBER _________________________
SOCIAL SECURITY OF PRIMARY INSURED MEMBER:_____________________________________________
IN THE EVENT I CANNOT BE REACHED IN AN EMERGENCY, I HEREBY GIVE PERMISSION TO THE DIRECTOR/
CHAPERONES TO SECURE PROPER MEDICAL TREATMENT, AND IF NECESSARY, TO TRANSPORT BY AMBULANCE,
HOSPITALIZE, AND TO ORDER INJECTION, ANESTHESIA OR SURGERY FOR MY CHILD LISTED ON THIS FORM.
PARENTS’/GUARDIANS’ NAME:_________________________________________________________________
P L E A S E P R I N T
PARENTS’/GUARDIANS’ SIGNATURE:____________________________________ DATE: _________________
____________________________________ DATE:_________________
HOME PHONE: _________________________________ WORK PHONE: ________________________________
NEAREST RELATIVE NAME:_____________________________________ PHONE:_______________________
STUDENT/FAMILY IS RESPONSIBLE FOR ALL MEDICAL COST INCURRED DURING THIS TRIP!
STUDENT SIGNATURE: ____________________________________________ DATE:______________________
WITNESS SIGNATURE: _____________________________________________ DATE:______________________
Form #119
8/98

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