Field Trip Medical Release Form

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Middleton High School
This form is used for recording parental permission for medical and/or surgical treatment in
case of medical concerns on a field trip
. A notarized signature is required for an overnight or out-of-state field trip.
Student Name: __________________________________ School: ___________________________________
Date of Birth: ___________________________________ Student #: _________________________________
Location of Field Trip: ____________________________ Date(s) of Field Trip: ________________________
As the parent and/or legal guardian of (print student name): ________________________________________,
I authorize Hillsborough County Public Schools, its agents, employees, and other officers to procure and
consent to any medical emergency treatment, including hospital care, to be rendered to my child by or under
the supervision of a licensed health care provider. The parent/legal guardian is responsible for any fees or costs.
My signature below represents consent and agreement to the matters stated above.
____________________________________________ ___________
Parent/Guardian Signature
STATE OF FLORIDA, COUNTY OF ________________________________________________________
SUBSCRIBED and sworn to before me, a Notary Public, this _____________ day of ____________, 20___.
Signature of Notary: ______________________________ Print Name: ______________________________
Medical Insurance Company:
Policy #:
Student's Address:
Father's Name:
Phone (Day):
Business Name (if applicable):
Phone (Evening):
Mother's Name:
Phone (Day):
Business Name (if applicable):
Phone (Evening):
Family Physician's Name:
Physician Address (street, city, state):
Check any health conditions that apply (if none, leave blank). Allergies __ Asthma __ Diabetes __ Seizures __
Heart condition __ Other (please describe):
Medications prescribed:
Hospital preference:
NOTE: In the event of an emergency medical situation, the chaperone/teacher will call 911 and all attempts
will be made to contact the student's parent/guardian regarding the emergency.
Distribution: Office, Teacher to take original on field trip
SB 77506 (Rev. 4/24/14) BMT 5/20/14
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