FITCHBURG PUBLIC SCHOOLS MEDICAL INFORMATION FORM IN CONNECTION WITH FIELD TRIP (Student Name) CO My student has no health/medical problems at this time and is not on medication at this time (please complete the insurance, sign on the bottom and return to your school as soon as possible). oR C1 My son/daughter has the following medical problem(s) of which the Trip Leader should be aware (e.g., asthma, bee stings): ‘My son/daughter needs to take the following medications or epinephrine in the manner specified below: ‘The following are the medications or foods or other items to which my son/daughter is allergic: Insurance Information Insurance company that covers your child: Policy number: ‘Name of primary person insured: agree to work with the school nurse prior to the field trip to establish a medication administration plan for my son/daughter. I also expressly consent tothe school personnel who will be onthe field trip and who have been trained in the administration of medication and epinephrine to administer the required medication to my son/daughter, In the event of illness or injury to my son/daughter while on this field trip, | expressly consent to the administration of the Fitchburg Public Schools and their authorized agents seeking, obtaining and authorizing the administration of medical treatment for Imy son/daughter, and, ifnecessary, transporting my son/daughter to medical facility for treatment. I understand and acknowledge that I will bear the sole cost and expense for any medical treatment that my son/daughter may receive Further, I expressly authorize the Fitchburg Public Schools and their authorize agents to act on my behalf a parent of my son/daughter while participating inthis field trip. I have read this Medical Information Form in Connection with Field ‘rips and understand is terms. I sign it voluntarily and with full knowledge of its significance. Signature of Parent/Guardian Date Home Phone Number Work/Cell Phone Number ‘The Fitchburg Public Schools insures employment, educational opportunites and affimative action, regarcless of race, religion, color, reed, national origin, sex, sexual orentation, or dsabilty, in compliance with Tile VI, Ik Chapter 622, IDEA 2004 and section 564, MGL. (Ch. 76, Section 5. Questions related to this non-ciscrmination regulation must be addressed to: Mr. Richard Zena, Grievance Offee, 376 South Steet, Fichbury, MA 01420, (978) 345-2215 |AForms\FPS Medical Infor Form - Field Trp.doeFITCHBURG PUBLIC SCHOOLS MEDICAL INFORMATION FORM IN CONNECTION WITH FIELD TRIP (Student Name) 1 My student has no health/medical problems at this time and is not on medication at this time (please complete the insurance, sign on the bottom and return to your school as soon as possible). oR Cl My son/daughter has the following medical problem(s) of which the Trip Leader should be aware (e.g,, asthma, bee stings): ‘My son/daughter needs to take the following medications or epinephrine in the manner specified below: ‘The following are the medications or foods or other items to which my son/daughter is allergic: Insurance Information Insurance company that covers your child: Policy number: Name of primary person insured: __ agree to work with the school nurse prior tothe field trip to establish a medication administration plan for my son/daughter. T also expressly consent tothe schoo! personnel who will be onthe field trip and who have been trained in the administration of medication and epinephrine to administer the required medication to my son/daughter. In the event of illness or injury to my son/daughter while on this field trip, | expressly consent to the administration of the Fitchburg Public Schools and their authorized agents seeking, obtaining and authorizing the administration of medical treatment for Imy son/daughter, and, ffnecessary, transporting my son/daughter to medical facility for treatment, 1 understand and acknowledge that I will bearthe sole cost and expense for any medical treatment that my son/daughter may receive. Further, I expressly authorize the Fitchburg Public Schools and their authorize agents to act an my behalf as parent of my son/daughter while participating in this field trip. 1 have read this Medical Information Form in Connection with Field ‘Trips and understand its terms. I sign it voluntarily and with full knowledge of its significance. Signature of Parent/Guardian ~ Di Home Phone Number Work/Cell Phone Number Failure to complete this form will prevent your child from attending the field tri ‘The Fitchburg Public Schools insures employment, educational opportunities and affimatve action, regarsess of race, religion, coor, creed, national origin, sex, sexual orentation, or dsabily, in compliance with Tie VI, Ik Chapter 622, IDEA 2004 and section 564, MGL. Ch, 76, Section 5. Question related to this non-cscrmination regulon must be addressed o: Mr. Richard Zeena, Grievance Offer, 376 ‘South Street, Fitchburg, MA.01420, (978) 345-2215 |AForms\FPS Medical Infor Form FleldTrp.doeESCUELAS PUBLICAS DE FITCHBURG FORMULARIO DE INFORMACION MEDICA EN CONNECTION LOS PASADIAS ESCOLARES. Nombre del Estudiante [] Mi hijo/hija no tienen ningiin problema medico ni esta tomando ningin medicamento en estos momentos (favor de completar la Informacion del Seguro, firme en la parte de abajo y devuelva lo antes possible). {] Mihijo/hija tiene ellos siguiente(s) problemas) de salud que la persona encargada del pasadia escolar debe saber (ejemplo: fatiga, picada de abispa): Mi hijo/hija necesita tomar ellos siguiente(s) medicamento(s) de la manera que se indica abajo: Los siguientes medicamentos, comidas u otra cosa a la que mi hijo/hija es alergico(a): Informacién del Seguro Médico: Compafiia de Seguro que cubre a su hijo/hija: Numero de Poliza: Nombre de la persona primaria: Yo trabajaré con la enfermera escolar para implementar 6 establecer un plan de como administrar los medicinas a mi hijo/hija. Tambien doy el concentimiento al personal escolar que participaré en los pasadias escolares y que han sido entrenados en la administracién de medicinas y epinephrine cuando sea Fequerido por mi hijo/hija. En el evento de enfermedad o ser lesionado mi hijo/hija durante el pasadia, doy mi concentimiento a la administracién de las Esculas Puiblicas de Fitchburg y agentes autorizadas en buscar y obtener la autorizacién de proveer tratamiento médico para mi hijo/hija y si es necesario transportar mi hijo/hija a una facilidaad medica para tratamiento. Y entiendo y acepto que soy responsable de cualquier costo incurrido por cualquier tratamiento medico que reciba mi hijo/hija. Ademas, exprecivamente autorizo a las Escuelas Publicas de Fitchburg y agentes autorizados en actuar como padres de mi hijo/hija durante su participacién en el pasadia. Yo he leldo la informacién médica en ‘coneccién con los pasadias escolares y entiendo sus terminos. Yo firmo voluntariamente y tengo conocimiento de lo que significa. Fecha Numero de teléfono de la casa Numero de teléfono del trabajo 6 Cellular Reusar a comp! sta forma impedira que su hijo asista a los pasadias escolares