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This form must be completed for all out-of-district and overnight trips because there are times
when a student’s illness or injury requires the immediate attention of nearby doctors and/or
hospital. The school district employee in charge of the students will attempt to contact a parent,
guardian, or family doctor; however, in extreme emergencies, this signed form will be needed as
authorization for treatment of the student. (Students who have special medical problems and
those who require a specialized medical procedure should be accompanied by a parent/guardian
if possible.) Students requiring medication must have a Physician’s Medication Request form
completed and a parental consent form signed by the parent. All medication must be in a
pharmacy labeled container and administered by designated school employee.
I hereby give my permission to do whatever is deemed necessary in case of the illness or injury
of my child,
, in the event that none of the persons listed below can be
contacted. I give my full permission for medical services to be rendered for my child by the
attending emergency physician or sub specialist.
Business Phone:
____________________________________ Home Phone:
Name of Parent or Guardian
Address City State Zip
Name, Address, & Phone Number of Individual to Contact Other Than Parent or Guardian
Name & Address of Insurance Company
(Check one) Individual Policy ________________ Group Policy _________________________
If Group Policy, Name of Employer_________________________________________________
Policy No.______________ Group No._______________ Contract No.____________________
Name, Address, & Phone Number of Family Doctor
_______________________________________ Date:
Signature of Parent or Guardian
Form 829A NOTE: This completed form must be in the possession of the teacher at all times
during the trip.
11-12 SY Bulletin Number One
Revised: 01/24/2012