Form H-18 - Medical Emergency Information For School Trip - 2013

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P P
P P
S S
RINCETON
UBLIC
CHOOLS
STUDENT SERVICES • 25 VALLEY ROAD • PRINCETON, NJ 08540• (609) 806-4206
Medical/Emergency Information for School Trip
Please complete the following in order to assist your child with any health problem and/or
emergency.
1.
Is the student presently under the care of a physician for any
particular reason?
Yes____ No____
If yes, please explain._____________
________________________________________________________________________
2.
Is there any medical limitations or condition that would affect your
child on this trip?
If yes, please explain.____________________________
________________________________________________________________________
3.
Is there any medication, including over-the-counter medications that
your child needs to take while on this trip?
Yes____ No____
If yes,
what medication and for what reason?____________________________________
________________________________________________________________________
Attached are consent forms for your doctor to fill out.
Doctor's forms are to be returned to the school nurse as soon
as possible, no later than two days before student leaves on
the trip.
4.
Does the student have any known allergies?
Yes____ No____
If yes,
please explain._________________________________________________________
________________________________________________________________________
5.
Date of last Tetanus Booster.___________________________________________
EMERGENCY INFORMATION
Student's Name___________________________________Date of Birth________________
Last
First
Address_____________________________________________Home Phone________________
Father/Guardian____________________Home Phone___________Work Phone____________
Mother/Guardian____________________Home Phone___________Work Phone____________
If unable to reach parent/guardian in case of emergency, contact:
Name_________________________________________________Phone Number_____________
Family Physician_____________________________________Phone Number_____________
In case of an accident or serious illness, I understand that the
school will contact me.
If the school is unable to reach me, the
administrator in charge has my permission to obtain the services of a physician
and/or hospital until I can be reached.
Insurance Company__________________________________Policy Number_____________
Parent/Guardian Signature____________________________________________________
H-18 [11-19-13]

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