Form C Sample 2016-2017 Week Without Walls Medical Information and Consent Form Please return to the MS Office by November 27, 2016
Electronic Medical Information Collection: ASD collects student health information including medical conditions, allergies, personal medications, and dietary preferences through an online Health Information Update Form emailed to parents. The form must be completed for every student before travel.
Consent for Emergency Treatment: As the parent/guardian of ____________________________________________________, I authorize physicians and/or other medical personnel, at the direction of the trip chaperon, to provide medical care to my child while he/she is participating in this trip, including examining, treating, prescribing medication for his/her care. I understand that the trip chaperon will, to the greatest extent possible, consult with me concerning the reasons for and effects of all such care. Recognizing that it may be difficult to reach me, I hereby expressly authorize the trip chaperon to permit commencement of treatment when, in the professional judgement of the physicians or medical personnel involved, such treatment is medically necessary to protect the life, health, or mental well being of my child. In authorizing such emergency treatment, agree to accept the determination of the treating medical personnel. I give this authorization on the condition that the treating physician and/or trip chaperon will attempt to contact me, if at all possible, before the treatment or examination is rendered. I agree to pay all costs, charges, expenses incurred in the relationship to providing this medical care. Dated: _______________________________________________
Parent Signature: _______________________________________ Print Parent Name: _________________________________________
Parent Signature: _______________________________________ Print Parent Name: _________________________________________
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