Science Safety
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 | _______________________________________________ |
