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The form requires selecting either consent (including provider and hospital contact details, transfer authorization, and limits on major surgery) or refusal to consent, with required signatures and 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\nfield trip on   to    \n(Date of event) (Destination)  \nTo enable parents/guardians to authorize the provision of emergency treatment for students who become ill or injured while under school authority when parents/guardians cannot be reached the Emergency Medical Authorization form, attached to this permission slip, MUST be completed.  \nParent/guardians must choose between Part I – To Grant Consent on the Emergency Medical Authorization form or Part II – Refusal to Consent on the Emergency Medical Authorization form.  \nI grant permission for my student to attend the above listed field trip and verify by my signature that I have completed the Emergency Medical Authorization information.  \n(Date) (Print name of Parent/Guardian)  \n(Contact Phone Number) (Signature of Parent/Guardian)  \nEMERGENCY MEDICAL AUTHORIZATION  \nSchool:    \nStudent Name:   Birth Date:   Grade:    \nAddress: Telephone:  \nPurpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.  \n\n| Parent or Guardian Information: |  | Home Phone | Work Phone | Cell Phone | E-mail Address |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Mother’s Name: |  |  |  |  |  |  |\n| Father’s Name: |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| Alternate Contact Name: |  |  |  |  |  |  |\n| Address: |  |  | Relationship to child: |  |  |  |\n| PART I OR PART II MUST BE COMPLETED |  |  |  |  |  |  |\n|  | PART I -TO GRANT CONSENT\u003Cbr>I hereby give consent for the following medial care providers and local hospital to be called:\u003Cbr>Doctor:   Phone:\u003Cbr>Dentist:   Phone:\u003Cbr>Medical Specialist:   Phone:\u003Cbr>Local Hospital: ~~ ~~ Emergency Room Phone:\u003Cbr>• In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.\u003Cbr>• This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.\u003Cbr>• Pertinent health information will be shared with appropriate school staff only on a need-to-know basis.\u003Cbr>• Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairment to which a physician should be alerted:  \u003Cbr>\u003Cbr>\u003Cbr>Date Signature of Parent/Guardian\u003Cbr>PART II – REFUSAL TO CONSENT\u003Cbr>I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency\u003Cbr>treatment, the school authorities may take the following action:  \u003Cbr>\u003Cbr>Date Signature of Parent/Guardian |  |  |  |  |  |\n|  |  |  |  |  |  |  |","cbCaidlhq7rfAw2F","https://ap.wps.com/l/cbCaidlhq7rfAw2F","pdf",71473,"English","# Field Trip Permission\n## Student and Trip Details\n## Emergency Medical Authorization Notice\n# Emergency Medical Authorization\n## Student Information and Purpose\n## Parent or Guardian Information\n## Part I: To Grant Consent\n## Part II: Refusal to Consent","[{\"question\":\"What information must be completed for the field trip permission portion?\",\"answer\":\"The student’s name and birth date, the field trip destination and event date, and the parent/guardian’s signature with the completed emergency medical authorization information.\"},{\"question\":\"How do parents/guardians authorize emergency treatment if they cannot be reached?\",\"answer\":\"By completing the attached Emergency Medical Authorization and selecting Part I to grant consent, which allows emergency providers and a local hospital to be contacted and enables necessary treatment and transfer.\"},{\"question\":\"What are the limits on major surgery under the emergency medical authorization?\",\"answer\":\"Major surgery is not covered unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity, are obtained before the surgery is performed.\"}]","Field Trip Permit and Emergency Medical Authorization - Consent and Refusal Form | PDF",1789130702]