School Field Trip Medical Release Form

Student Information

Student Name

Grade

Date of Birth

Teacher

Parent/Guardian Information

Parent/Guardian Name

Phone Number

Emergency Contact Name Emergency Contact Phone

Medical Information

Allergies Medications (name & dosage) Existing Medical Conditions Health Insurance Provider Policy/Group Number

Medical Release Authorization

I hereby give permission for the above student to attend the school field trip and authorize emergency medical care if necessary. I understand all effort will be made to contact me before such care is administered.

Parent/Guardian Signature

Date