FIELD TRIP & EMERGENCY PROCEDURE PERMIT

WAPAKONETA HIGH SCHOOL

Student’s Name _______________________________________Phone__________________

Address ____________________________________________________________________

Parent with whom child resides__________________________________________________

Whom should be contacted if unable to reach family ________________________________

___________________________________Phone __________________________________

The chaperone on this field trip DOES _____ DOES NOT _____ have my permission

to take my child to the nearest hospital for emergency treatment.

The following information is needed by the hospital or doctor not having access to the medical

history of the child:

Medication being taken________________________________________________________

Bleeder of Hemophilia ___________________ Date of last Tetanus Shot ________________

Physical Impairments _________________________________________________________

Other pertinent information:____________________________________________________

___________________________________________________________________________

Mark with an “X” any of the following conditions the child may have now and explain.

______ Allergies or Hay Fever _______________________________________________

______ Asthma____________________________________________________________

_____ Arthritis or Rheumatism_______________________________________________

______ Deafness or Hard of Hearing___________________________________________

______ Diabetes ___________________________________________________________

______ Epilepsy___________________________________________________________

_____ Heart Condition_____________________________________________________

_____ Loss of Vision______________________________________________________

_____ Rheumatic Fever____________________________________________________

_____ Skin Allergies ______________________________________________________

_____ Speech Impairment___________________________________________________

_____ Spine or Back Injury__________________________________________________

Parent Signature ____________________________________ Date_________________

Field trip to :________________________________________