THE SCHOOL BOARD OF SARASOTA COUNTY, FLORIDA PUPIL SUPPORT SERVICES
1960 LANDINGS BOULEVARD, SARASOTA FL 34231-3331 TELEPHONE: (941) 927-9000
EMERGENCY MEDICAL/TREATMENT FIELD TRIP CONSENT FORM
Date: _______________________
Name of Student: _______________________________________________ Date of Birth: _________________
Last First Middle
Home Address: _________________________________________________________________________________
Street City Zip Code
Parent/Guardian: ____________________________________________________Relationship: ______________
Address of above (if different)____________________________________________________________________ Street City Zip Code
Home Phone: ___________________ Work Phone: ___________________ Cell Phone: ____________________
Please list a person other than the parent or guardian who could be contacted in case of an emergency below:
Emergency Contact:______________________________________Phone #: __________________________________
Is above student allergic to foods, medications, or insects? Yes No
If Yes, please list what they are and emergency medication/treatment, if any: _____________________________________________________________________________________________
_____________________________________________________________________________________________
Does the above student have any chronic medical problems (such as asthma, diabetes, seizures)? Yes No
If Yes, please list and describe medical requirements for field trip: _____________________________________________________________________________________________
_____________________________________________________________________________________________
Does the above student take any daily medication? Yes No
If Yes, please compete the medication treatment authorization form (if not previously on file in the school Health Room)
and please list the medication and time to be administered: ________________________________________________
_____________________________________________________________________________________________
Family Physician: ___________________________________ Physician Phone: ____________________________
In case of serious illness or injury where immediate care is needed, the school or its representative has my permission to contact the appropriate emergency medical service. The emergency medical service has my consent to provide necessary treatment or transportation for my child. I then request that I be notified of the situation. The undersigned will be responsible for emergency treatment cost.
In the case of an accident or illness where immediate treatment of my child is not indicated, but where (s)he is unable to remain at the field trip, I request that the school contact me or my designee to arrange transportation for my child. If the school is unable to contact me, I request that the other person listed on this form be contacted and requested to care for my child. I understand that I must notify the school if there are any changes in this health emergency information.
In case of non-life threatening emergency, list hospital preference: ______________________________________
Parent/Guardian Signature: ____________________________________ Date: _________________________
RET: Master, ESY The School Board of Sarasota County complies with State Statutes on Veterans’ Preference and Federal Statutes on 005-96-SEC-BUSDupl., OSA non-discrimination on the basis of race, color, sex, religion, national origin, age, disability, marital status or sexual orientation Rev. 5/9/04
