Health History Form for Extended Day, Overnight, or Out-of-State Field Trips

Health History Form for Extended Day, Overnight, or Out-of-State Field Trips
Student's First and Last Name

First NameLast Name
Date of Birth

MonthDayYear
Date
School
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Provider
Medical Provider Name
Clinic
Medical Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Information

To be used in the event of urgent or emergency medical treatment.
Insurance Provider
Insurance Provider Telephone #
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber Name
Policy Number:
Health Conditions
Has your student been diagnosed with any of the following conditions by a medical provider (check all that apply)? If any condition requires medication or medical intervention, please specify details and complete the medication section. Additional documentation from a medical provider may be required.

Other
Description of Medical Condition
Medication Administration
Is your student currently taking any medication (including emergency medications?
Authorization for Medication Administration and Provider Communication
I hereby give my permission for designated school personnel or volunteers to give the above medication(s) as directed and to communicate with the medical provider(s) as necessary. I further agree to hold the Verona Area School District and its employees administering the medication(s) harmelss for any claims arising from the administration of this medication. All medications will be sent with my child in the original pharmacy-labeled container (prescription medication) or the original manufacturer's packaging (non-prescription medication). I understand all controlled substances, including ADHD medications, require written orders from the prescribing physician and must be stored and administered by a designated staff member or chaperone.
Parent/Guardian Signature
Authorization for Self-Administration of Medication
I give permission for my child to administer their own medicaiton(s), as indicated above, during the school-sponsored trip. I understand all prescription medication requires written orders from the prescribing physician, including medications that are self-administered.
Parent/Guardian Signature
In the event of EMERGENCY CONDITIONS, the following procedure will be followed by the Verona Area School District
1. Emergency first aid will be given by the teacher, chaperone, or other qualified person.
2. In the case of serious injury/illness, the child will be transported to the nearest hospital for examination by a healthcare provider
3. Reasonable effort will be made to contact the parent/guardian referenced above.
To the best of my knowledge, my child is in good health and free of any communicable disease. In the event I am unable to be reached, I hereby consent to my child's treatment as recommended by the physician/hospital. I understand that I as a parent/guardian am responsible for the cost of the service rendered.
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Health History Form for Extended Day, Overnight, or Out-of-State Field Trips

Medical Provider

Health Insurance Information

Health Conditions

Medication Administration

Authorization for Medication Administration and Provider Communication

Authorization for Self-Administration of Medication

In the event of EMERGENCY CONDITIONS, the following procedure will be followed by the Verona Area School District