Mid-Del Schools Authorization for Emergency Medical Treatment
for Students on Out of State/Overnight Trips

Name of Student __________________________ Age________ Date of Birth _____________

Address______________________________________________________

Telephone Numbers:                     Home Phone: ____________________           

 Father’s Work Number: _____________Mother’s Work Number: _______________________

Emergency Contact Name and Phone Number:______________________________________
(in the event none of the above are available)

Contact Parent/Legal Guardian Signature__________________________________________

Allergies/Prescription Medications

           Is the student allergic to any medications? Yes  or  No

           Will the student be on prescription medication during the trip?  Yes   or  No

If yes to either, please list and/or explain below. (If needed attach additional sheets)

___________________________________________________________________________

___________________________________________________________________________

Insurance Information: Name of Insurance Company ___________________________________

Group #__________________  Member#_________________  Effective Date_____________

Employer_______________________ Primary Care Physician _________________________

Phone Number ________________________________

I, ______________________________ give permission for Becky Scott to secure emergency medical treatment for ______________________________while (full name of son/daughter) participating with the CAMS Band on school approved trips. I understand that the cost of any such treatment will be my responsibility (or that of my insurance company). I also understand that every effort will be made to contact me as soon as possible.

Signature of Full Name of Parent/Legal Guardian (must be a notarized signature)

________________________________________________________________________
Please use this space for notary information.