Field Trip Health Form (Page 2 of 2) in pdf

Health History, Continued

2. Complete the following:

a. Are there any specific activities to be encouraged, limited or avoided?

YES

If yes, please explain:_____________________________________________________

______________________________________________________________________

Is participant able to swim?

YES

Circle level of ability:

beginner intermediate

advanced

Does participant have a current tetanus shot?

YES

Date of shot: __/__/__

List current medications (please send with directions to be administered during trip):

_______________________

______________________

________________________

I give permission for me/my child to be administered the following as needed for minor

discomfort while on the educational field trip: (check all that apply)

Tylenol

Advil

Cough drops

Sudophin

Antacid

Other:__________

Do you/your child have any special dietary considerations?

YES

If yes, please provide detailed information

: ____________________________________________________

Provide any other important health related information about yourself/your child:

_____________________________________________________________________________

Read and sign the following:

This health history provided in this document is correct so far as I know. I understand that

participation in this field trip and classroom activities is entirely voluntary. I understand that the field

trip may involve: swimming, wading, boating (by canoe and/or motor), hiking, camping, fishing and

other outdoor activities. I know and understand the risks and dangers involved in the above-named

activities and I know and understand that unanticipated dangers might arise. Field trip staff will do

everything possible to minimize potential hazard or risk.

_____________________________________________________

___________________

Parent/guardian signature or adult participant signature

Date

Field Trip Health Form Page 2