Lane
Ogle
Periods 1-4
SESSION
Complete and return form with payment ($135) to
your student’s social studies teacher by 10/09/2016.
1
Parental Permission/Medical Form
for Camp Tecumseh Field Trip
Full Name of Student _____________________________ Student’s Gender: Male or Female
(Please circle gender)
Cost: $135.00 (Make check out to “RJH”)
Meals: Bring a sack lunch (only in containers that can be disposed of after eating) for the FIRST DAY of
CAMP ONLY – all other meals will be provided
Emergency Information
In case of an emergency I can be reached at the following telephone numbers:
Parent/Guardian Name __________________________________________________________________
Home:
_____________________Work:_____________________Cell:________________________
Email: _________________________________
Parent/Guardian Name __________________________________________________________________
Home:
_____________________Work:_____________________Cell:________________________
Email: _________________________________
Student’s Doctor: _____________________________________ Doctor’s Phone: ____________________
My child has the following health conditions or allergies: ________________________________________
_____________________________________________________________________________________
The nurse has permission to administer the following over-the-counter medications to my student, if
needed. Please mark all that apply:
____ Tylenol
_____ Ibuprofen
_____Sudafed
_____ cough drops
_____ Benadryl
If unable to reach Mr. /Mrs. ___________________________________, parent/guardian, at the emergency
numbers listed, I/we hereby grant permission for a licensed health care professional and or treatment center to
administer to my child, appropriate medical care in the event of an accident, illness, or emergency.
YOU MUST SIGN HERE! :
Parent/Guardian Signature: ______________________________________ Date: _________
My signature above also gives permission for my student to attend this school sponsored and chaperoned field trip.
CHECK THIS BOX IF . . . your child takes medication (over the counter or prescriptions)
other than those listed above. This medication must be dropped off to the
school nurse from 3pm - 6:30pm on Wednesday, Oct. 26th in the original bottle, or will
be accompanied by a note from a physician. Please send ONLY the amount of
medication needed for the days at camp. Please contact Nurse Murray if you have any
questions.