Field Trip Student Medical Consent Form
Student Information
Full Name
Date of Birth
Grade
Parent/Guardian Contact
Parent/Guardian Name
Phone Number
Email Address
Emergency Contact
Emergency Contact Name
Emergency Phone Number
Relationship to Student
Medical Information
Medical Conditions / Allergies
Current Medications
Primary Physician Name
Physician Phone Number
Health Insurance Carrier
Policy Number
Consent
I authorize medical treatment for my child in the event of an emergency.
I give permission for my child to participate in the field trip.
Parent/Guardian Signature
Date