Gaylord Community Schools
Gaylord, MI 49735
FORM E STUDENT-AUTHORIZATION FOR EMERGENCY MEDICAL REQUIRED FOR ALL TRIPS
Emergency medical card may be used in place of Form E
IMPORTANT: This information must be taken along on the field trip in case of an emergency
STUDENT:________________________________
DATE OF BIRTH:___________________________
TODAY’S DATE:_________________________
I/We, the parent(s) or legal guardian(s) of above student, hereby delegate to the School System the authority to authorize and consent to any or all medical, surgical, dental, optical, hospital care, or treatment, in case of emergency, while on an educational trip. Such treatment is to be rendered by or under the jurisdiction of a duly licensed physician or dentist. The School System is fully authorized to act in accordance with best judgment in any such emergency and is absolved from any liability or financial responsibility to connection therewith.
X_______________________________________________ Home Telephone No._________________________
Signature of Parent or Guardian
Home Address_________________________________________________________________________________
___________________________________________ _________________________________________________
Mother’s/Father’s Place of Employment Work & Cell Phone Numbers
______________________________________________________________________
Medical-Hospital Insurance Company_______________________________________________________________
Name of Subscriber_____________________________________________________________________________
Group No._____________________Service No__________________Contract No___________________________
EMERGENCY INFORMATION
Please list any allergies your child has:______________________________________________________________
Please note any special needs your child has (dietary, medical conditions, etc. You may attach separate sheet).
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
________________________________ ____________________________ ____________________________
Name of Physician Address Telephone No.
_________________________________ ____________________________ ____________________________
Name of Dentist Address Telephone No.
_________________________________ ____________________________ ____________________________
Name of Eye Doctor Address Telephone No.
If unable to contact spouse, please call (local contact):
________________________________ ____________________________ ____________________________
Name & Relationship to student Address Telephone No.
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