GUARDIAN CONSENT FOR MEDICAL TREATMENT
GUARDIAN CONSENT FOR MEDICAL TREATMENT
I, , as legal guardian of
(Guardian’s name)
, authorize Hamilton County Schools to
(Child’s name) (Date of birth)
grant consent for medical treatment for my child during his/her absence from school.
on the TN, GA/SC, NC, VA/DC
Date (Circle one)
I assume all financial responsibility for medical costs over and above insurance benefits.
Guardian’s Signature Date
Mother / Guardian Father / Guardian
|Name: |Name: |
|Address: |Address: |
|City/State/Zip |City/State/Zip |
|Home Phone: |Home Phone: |
|Cell/Beeper: |Cell/Beeper: |
|Employer: |Employer: |
|Work Phone: |Work Phone: |
|E-mail: |E-mail: |
Emergency Information (other than parent):
Contact Person Phone:
Contact Person: Phone:
Doctor’s Name Phone:
Both sides of this form MUST be completed before leaving Chattanooga.
Medical Insurance (mandatory)
Company Group Number
Pre-admission Telephone Number (if required)
Please list any allergies or medical problems:
Last tetanus shot (year)
Routine medications taken by child
Special diet requirements (vegetarian, diabetic, etc.)
NOTE: In the event of an emergency medical situation, even with the form, the chaperone will attempt first to contact the student’s parent/guardian.
PERMISSION AND MEDICAL RELEASE FORM
__________________________ has my permission to travel on the TN, GA/SC, NC, VA/DC (circle one)
CSAS Junior College Trip, .
Date of Trip
Permission for Tylenol (acetaminophen) or Advil (ibuprofen)
My child may receive Tylenol or Advil if the chaperones deem it necessary.
______ yes ______ no
Permission for Benadryl (diphenhydramine)
My child may receive Benadryl Liquid (diphenhydramine) if the chaperones deem it necessary.
______ yes ______ no
Release
I hereby release Hamilton County Schools from all responsibility, excluding negligence, for any injuries and/or illness during this trip.
Guardian Signature:
Relationship: Date:
Both sides of this form MUST be completed before leaving Chattanooga.
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