Medical Treatment Form

LIVERPOOL CENTRAL SCHOOL DISTRICT

EMERGENCY MEDICAL TREATMENT AUTHORIZATION INFORMATION

(Required for trips in excess of 50 miles one-way or 5 hours duration)

TO WHOM IT MAY CONCERN: I, the undersigned, being the parent, legal guardian or next-of-kin hereby authorize any necessary medical treatment for:

(Pupil Name) (DOB) (Address)

City, State, Zip

In regard to such pupil, I submit the following information:

Allergies to foods, medication, etc. (if none, so state; if yes, specify):
Special medical problems (If none, so state; if yes, specify):
Is this student now under medical care? If so, describe the nature of illness and treatment:
Does this student carry medication on person?
Purpose:
Date of last tetanus:
Family physician/clinic: Phone: Office Address:

Signature of Parent / Legal Guardian: Date

Printed or typed name of person signing above: Relationship to pupil:

Telephone: Bus. Mother

Bus. Father Cell Mother

Cell Father

Emergency name(s) and number(s) if above are not available:

Insurance Company: Policy #

*Sworn to and subscribed before me this

day of , 2008

Notary Public