Click on title for a copy of the form.
- STUDENTS must complete the whole form
- CHAPERONES and STAFF
- Student’s Name = Your name
- Student’s Cell # = Your cell #
- Parent/Guardian’s Name = Your emergency contact person
- Emergency contact number = Your emergency contacts phone number
- Everyone must complete this form.
- DO NOT MAIL IN THIS FORM! Give it to Mr. Z. on April 24.
- The person going on the trip needs to PRINT their name on the NAME line.
- PARENTS- You must sign your child’s form!
- Everyone going on the trip must complete pages 1 & 2 of the medical form. This include staff, truck drivers, and chaperones.
- A parent signature is required at the bottom of BOTH page 1 & page 2 (See Below)
- Write the TRIP PARTICIPANT’S NAME at the top of page 2.
A parent or guardian’s signature is required at the bottom of page 1.
Write the trip participant’s name at the top of page 2.
A parent or guardian must sign the bottom of page 2.
- Make sure you have marked allowed or NOT allowed for the medications that can be administered on page 2.
- If your child receives medication during school hours from the school nurse, have your child’s physician complete this form and return it to Mr. Zettlemoyer no later than May 1.
- If your child receives medication at home that will now need to be administered by the school nurse on the trip, have your child’s physician complete this form and return it to Mr. Zettlemoyer no later than May 1.
- A SEPARATE FORM NEEDS TO BE COMPLETED FOR EACH MEDICATION THAT YOUR CHILD RECEIVES!