Wooster City Schools Field Trip Permission Form

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Wooster City Schools
FIELD TRIP PERMISSION FORM
______________________________________________________________________________ Date of Birth __________________
(Student’s name)
has my permission to attend the _______________________________________ at ______________________________________
(describe activity)
(location of activity)
on _______________________ It is understood that my child will travel to and from this activity by ________________________
(date of activity)
(method of transportation)
and is responsible for his/her own conduct by following all school rules and regulations, and that the school will not assume any liability.
________________________________________________________________ _________________________________________
(parent/guardian signature)
Date
EMERGENCY MEDICAL AUTHORIZATION
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or
injured while under school authority, when parents or guardians cannot be reached.
List only the names (first and last) of those who have authority to make decisions in an emergency situation involving this
student. Then, indicate on the line to the left the order in which you desire contact attempts to be made based on availability
(i.e., 1st, 2nd):
1st
Name
Daytime Work
Home Phone
Cell Phone or pager
2nd,
Phone
etc
Mother
Father
Step Parent
Guardian
(if necessary)
Other 1
Other 2
Known Allergies ______________________________________________________________________________________________
Current Medications __________________________________________________________________________________________
Health Concerns (diabetes, seizures, asthma, etc.) ________________________________________________________________
___________________________________________________________________________________________________________
Physical Impairments _________________________________________________________________________________________
(Part I or Part II must be completed)
:
I. CONSENT FOR TREATMENT:
In the event of illness or injury, I hereby give consent for the following medical care providers and local hospital to be called:
Preferred Physician:_______________________________________________ Office #:___________________________________
Preferred Dentist:_________________________________________________ Office #:___________________________________
Medical Specialist:________________________________________________ Office #:___________________________________
Preferred Hospital:________________________________________________ Phone # ___________________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed
necessary by the preferred doctor indicated, or, in the event the designated preferred practitioner is not available, by another licensed physician or
dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical
opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Parent/Guardian Signature: __________________________________________________________ Date:_____________________
OR
II. REFUSAL TO CONSENT:
DO NOT COMPLETE PART II IF YOU COMPLETED PART I
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment,
I wish the school authorities to take the following action:
___________________________________________________________________________________________________________
Parent/Guardian Signature: __________________________________________________________ Date:_____________________
This information will be distributed to all necessary school personnel unless otherwise requested
Revised 6/07

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