Mfriends.org

Moorestown Friends Class of 2013
Project Graduation
Medical Information & Authorization to Treat
No School Provided Medical Personnel
Student Name
Parent Name
Emergency Contact:
Name
Health Information:
Chronic
Allergies
Describe the reaction
Treatment
Existing
problems
Dietary Restrictions
Medications
(provide details if student will be self-administering medications; students may only
self-administer medications prescribed by a physician for life-threatening conditions. Since
medical personnel will not accompany this trip neither the school nor the child may
administer medication for other conditions. Please call the school nurse if you have
questions)
Can your child have Tylenol, Pepto Bismol, or Benadryl as needed?
Tylenol – yes/no
Pepto Bismol – yes/no
Benadryl – yes/no
Tetanus Shot
Helpful Information
Family Physician Phone
Family Dentist Phone
Health Insurance Policy Number
Phone
Policy Holder
Social Security Number of Policy Holder
Medical Authorization
In the event that medical treatment and/or hospitalization and/or incidence of medical expenses of any description are required for my son/daughter for any cause, I hereby authorize and consent to all medical and surgical treatment and expenses deemed necessary by the attending physician. I appoint the leader(s) of the Moorestown Friends School program as guardian(s) of the person of my son/daughter and authorize him/her to make all decisions in loco parentis, including re- confirming this medical authorization by signing any required medical authorization forms. Moorestown Friends School Class
of 2013 Project Graduation
Student/Parent Agreement
A successful trip depends, in part, on the cooperation, positive attitude and good behavior of its participants. Moorestown Friends School’s expectations concerning community norms and appropriate student behavior – as outlined in the Student/Parent Handbook – will therefore be in effect during this trip. Violations of these norms and rules could result in a student’s being sent home early at the family’s expense, or other disciplinary action as determined by the administration. Parents must agree to come get student if trip leaders deem necessary In the case of an emergency, the trip leader will make every attempt to communicate with parents. Unforeseen circumstances may make this impossible. Therefore, the accompanying Medical Authorization form must be signed by the parent/guardian. Student’s Agreement:
I understand that I will be expected to participate fully and responsibly in the service involved in this trip. I agree to abide by MFS expectations for appropriate behavior, as outlined in the Student/Parent Handbook. Parents’ Agreement:
(parent names) give our/my child permission to participate in the June 8, 2013 through June 9, 2013 Project Graduation event. We understand that all school rules and policies will be in effect during the trip. We agree to release and hold harmless MFS, MFS employees and chaperones from any and all liability, loss, damages, claims or actions for bodily injury and/or property damage arising out of participation on this trip, in accordance with current state and federal law. I/we further understand that it will be my/our obligation to assume the full cost of the trip, as well as costs associated with early return, if my/our son/daughter is sent home for disciplinary reasons.

Source: http://www.mfriends.org/07/documents/PGMedicalRelease2013.pdf