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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