Medical Information Form with Important Contact Information

 

Horace Mann Middle School

I have read the information for the ski trip and give permission to my son/daughter ______________________________ to participate.

I understand and agree that while on this trip my son/daughter is required to comply with all the policies of the School District, particularly those pertaining to proper conduct and substance abuse.

Student’s Name: _________________________________________

Student’s Age: __________ Homeroom #: ________ Advisor: _____________________

Student’s Address: ________________________________________________________

Student’s Phone Number: __________________________________________________

 

Emergency Contact Numbers: Contact person(s) must be available on January 23, 2010.

 

Name: ____________________________________ Phone: _______________________

Name: ____________________________________ Phone: _______________________

 

*Are there any medical concerns that we should be aware of? (i.e. allergies, allergies to medication, asthma, diabetes, etc.) No________  Yes ________   If yes, please explain.________________________________________________________________

*No school nurse will be present on the above dates.

Health Care Insurance

Coverage __________________________________________________(company name)

Authorization, consent and release:

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention to my child ______________________________________.

However, if I can not be reached, I hereby authorize Franklin School Department to transport my child to the nearest medical facility or hospital and to secure my child for the necessary medical treatment. In consideration of this participation, the undersigned for ourselves, waive and release any and all rights and claims for damages that we may have against the Franklin School Department, their agents, and representatives, successors, and assigns for any and all injuries suffered by our child’s participation in the activity or while traveling to or returning there from. We further state that we have carefully read the forgoing release and know the contents thereof; we sign the name as our own free act.

 

Please sign below, where appropriate.

Father’s Signature: ______________________________________ Date: ____________

Mother’s Signature: _____________________________________  Date: ____________

Legal Guardian’s Signature: __________________________________ Date: _________