Manitoba

Manitoba Education

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Appendix H

Field Trip Medical Information Form

(Return to the school in a sealed envelope)

Name of student ___________________________________________________
Date of birth ___________________________________________________
Home address ___________________________________________________
  ___________________________________________________
Name of parent(s) / guardian ___________________________________________________
  ___________________________________________________
Home phone ___________________________________________________
Business phone(s) ___________________________________________________
In case of emergency
contact parents OR:
___________________________________________________
  ___________________________________________________
Phone ___________________________________________________
Manitoba Health No. ___________________________________________________
Travel insurance ___________________________________________________
Family doctor ___________________________________________________
Office phone ___________________________________________________
Office address ___________________________________________________
Home phone ___________________________________________________

 

Please describe any health problem, physical handicap, emotional difficulty, behavioural problem, or other factors which may limit full participation in the field trip:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Student is subject to (please check appropriate items):

___asthma ___ear ache ___fainting ___high blood pressure
___eye infection ___ear infection ___frequent colds ___sinus trouble
___bronchitis ___sensitive skin ___nightmares ___sleepwalking
___convulsions ___headaches ___bed wetting ___kidney problem
___nosebleed ___tonsillitis   ___motion sickness
___allergies (describe)_______________________________________________________

 

Student has received the regular immunization program administered in Manitoba, including diptheria, pertussis, whooping cough, tetanus (DPT), typhoid, smallpox, and polio vaccinations. Yes____ No____

Can the student swim? Yes____ No____

Does the student wear contact lenses? Yes____ No____

Medications: I would like my child to be given:

Name of Medication(s)

_________________________________________________________

Purpose and Dosage

_________________________________________________________

In case or emergency, I hereby authorize the physician selected by school personnel to provide necessary treatment for my child:

Signature(s) _______________________________________________
  _______________________________________________
Date _______________________________________________

 


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