Big South Fork 2009-10

Permission and Medication Authorization Form

Permission

I, ________________________________________________________, parent or guardian of ____________________________, gives my permission for ___________________________ to accompany the 8^th grade of St. Francis School (SFS) on its annual backpacking trip to the Big South Fork National Recreation Area.

Authorization for Medical Treatment

Parent/Guardian Name _________________________ Home Phone: ______________________ Work Phone: ____________________________ Cell Phone: ____________________________

Emergency contact and # if parents cannot be reached__________________________________

Insurance: ___________________________ Policy #: __________________________________

Child’s Physician ____________________________ Physician’s Phone #___________________

I/we the undersigned parents and/or guardian(s) of _____________(Student’s name),  do hereby grant permission to the responsible adults supervising this SFS field trip, to any hospital, to any physician, or any other organization providing medical treatment to_______________, during said field trip in the event that we are not readily available to give our permission for such treatment.

Furthermore, I authorize SFS staff to admit my child for medical care to a hospital or other medical facility, to administer first aid, to administer the over the counter medications, including but not limited to those indicated below, if my child feels the need to do so, and to make any medical decisions concerning my child in the event of an emergency.  Any medical expenses incurred on behalf of my child will be solely my responsibility.  This medical authorization is effective the entire time my child is in the care SFS during the BSF trip. 

Allergies

Please indicate any severe allergies of which we must be aware (attach additional pages if necessary):

Allergy	Symptom	Treatment

Finally, I do/do not (circle one) give permission for SFS staff to administer medicines from home, prescribed or over-the-counter.  (If sending medicine from home, please fill in the information below. Attach additional pages if necessary.)

Pharmacy and Prescription # _______________________________________________________

Name of medication and dosage ____________________________________________________

Reason for medication ____________________________________________________________

Dosage and time to be administered _________________________________________________

Possible side effects _____________________________________________________________

The medications must be given to SFS staff in an original container with the following information:  child’s name, physician’s name, name of medication, strength of medication, amount and time to be given.  DO NOT leave medicine in child’s possession or mix various medications in the same container.

I/we agree to hold any responsible adult who gives permission harmless and to release that individual from any liability in connection with granting such permission for treatment and, furthermore, we do hereby release, acquit, discharge, and covenant to hold harmless, St. Francis School, its agents and employees, from any and all actions, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in any way growing out of the granting of permission for any emergency medical care for my/our child,__________________  (Student’s name) during his/her participation in the above-described backpacking trip.

Parent Signature ________________________________________________  Date _________

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