In Class Field Trip FormBleckley County High School

Cochran, Georgia

From time to time the agricultural classes at Bleckley County High School will take field trips during class time. The trips will be pertaining to the instructional information of the class. These trips will only be off campus during the class time. Although this is an off campus activity, the students will be responsible for maintaining the same conduct as he/she is expected to display at school and will be subject to the same discipline procedures.

(Student’s Name)________________________________________________ has permission to participate in the off campus trips and activities of the agricultural classes. In the event of a medical emergency, I authorize the school to obtain through a physician of its choice any emergency care that may become reasonably necessary for the course of the activity or travel to and from the activity.

___________________________________________________Parent/Guardian Signature

Name of Insurance company_______________________________ Number ________________

In case of emergency the following person should be contacted:

Name ________________________________________Address ______________________________________(Include street, road or emergency road number)

Phone numbers where this person can be contacted:

________________________________ __________________________________

________________________________ __________________________________

Medical Information: Please list any medical conditions, allergies or other information that may be needed to treat the above student.

MEDICAL INFORMATION

1. Student Name ________________________________________________________________2. Student’s Address _____________________________________________________________3. Name & Phone Number of Family Physician ________________________________________4. Date of last physical examination _________________________________________________5. List allergies (medication, food, insect bites, bee stings, poison ivy,etc.)

____________________________________________________________________________6. List any medications currently taken_____________________________________________

____________________________________________________________________________7. Last Tetanus shot ______________________________________________________________8. History of heart condition, diabetes, asthma, epilepsy or rheumatic fever ______________

____________________________________________________________________________9. Any physical restrictions ________________________________________________________

____________________________________________________________________________10. Other conditions ______________________________________________________________

____________________________________________________________________________11. Has the student had: Measles ______ yes ______ no

Mumps ______ yes ______ noRubella ______ yes ______ no

12. In case of emergency, please provide contact information so that you can be notified at all times.In case of emergency, contact: _________________________________________________Relationship to student: ______________________________________________________Home Phone: ______________________________________________________________Work Phone: ______________________________________________________________Cell Phone: ________________________________________________________________Pager: ____________________________________________________________________

13. In case the above person cannot be contacted,Contact: __________________________________________________________________Relationship to student: ______________________________________________________Home phone: ______________________________________________________________Work phone: ______________________________________________________________Cell phone: _______________________________________________________________Pager: ___________________________________________________________________

Parent/Guardian Signature

______________________________________Parent or Guardian (Please Print)

_______________________________________ ___________________________Parent or Guardian (Signature) Date