MEDICAL RELEASE FORM ● EXTENDED FIELD TRIP

In the event of an emergency, my signature below constitutes permission for my child to receive medical evaluation and necessary treatment to ensure his/her safety. Such treatment may come from either my child’s physician or another physician or medical facility as deemed appropriate by the supervising Wayne Central staff member. As my Attorney In Fact, I give the supervising Wayne Central staff member my permission to execute any necessary documents in connection with the medical treatment including any required guarantee of payment.

Parent/Legal Guardian’s insurance carrier:………………………………………………………………….
Insurance ID No……………………………..
______________________________________________ ___________________________

Address:…………………………………………………………………………………………………………
Parent’s/LegalGuardian’s Name:…………………………………Home Telephone Number:…………
Father’ s/Guardian’s workplace………………………………… Work Telephone Number…………..
Mother’s/Guardian’s workplace:………………………………… Work Telephone Number……………

If you plan to be away while we are gone on the extended field trip, please indicate how we may contact you if the need arises: ……………………………………………………………………………..

Emergency contact (other than parent or legal guardian):

Name:………………………………………………Phone Number:……………………………..
Address:…………………………………………………………………………………………………
Relationship to student:………………..

Physician’s Name: ……………………………………………Phone Number: …………………………….
Dentist’s Name:……………………………………………… Phone Number:…………………………….
Medical insurance plan: …………………………………… ID Number: …………………………………

EMERGENCY INFORMATION