School Field Trip Medical Consent for Minor
Student Information
Full Name
Date of Birth
Grade
School Name
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Emergency Contact Name
Emergency Contact Phone
Medical Information
Allergies
Current Medications
Medical Conditions
Insurance Provider
Policy Number
Family Doctor Name
Doctor Phone
Consent
I authorize school staff to obtain medical attention for my child in the event of an emergency. I understand every effort will be made to contact me first if possible.
Parent/Guardian Signature
Date