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Authorization form (yellow form)

WASHINGTON DC/GETTYSBURG TRIP
LIABILITY AND MEDICAL RELEASE AND AUTHORIZATION
(YELLOW FORM)
I, _____________________________, the parent of ____________________________ accept full
responsibility for my child’s actions and behavior while on the Washington DC trip. In no way, will I
hold the chaperones responsible or liable for any damages, accidents, injuries or losses that may occur
throughout the course of the trip. I understand that I am liable for my child’s behavior during
unsupervised time, and the chaperones are not responsible for any damages, accidents, injuries or losses
that may occur during this trip (ie—sightseeing, shopping, eating, etc.). I also understand that there are
no monetary refunds.
I, the undersigned parent/guardian/custodian of ______________________________ authorize Teays
Valley West Middle School chaperones in any medical emergency situation to obtain any and all medical
care for said child in the event of an accident or injury which may arise during the course of the said trip.
I, ______________________________, the student accept full responsibility for my actions and my
behavior on this trip.
In no way will I hold the chaperones responsible or liable for any damages, accidents, injuries or losses
that may occur throughout this trip.
I, ________________________________, the student, also accept responsibility for my behavior and
actions during unsupervised time and the chaperones are not liable or responsible for any damages,
accidents, injuries or losses that may occur during this time. Unsupervised times include, but not limited
to, time in the hotel room, sightseeing, shopping, and eating.
I, the undersigned, have knowingly read and understood the consequences of the above written and
hereby voluntarily sign this authorization agreement and release.
Signed ____________________________ Date ___________________

Parent, Guardian or Custodian

Printed ___________________________

Parent, Guardian or Custodian

Signed ____________________________ Date ___________________


Printed ___________________________

Student Name
______________________________
Notary Public, state of Ohio
My Commission Expires: ___________________________
MEDICAL AUTHORIZATION FORM
Child’s Name: _____________________________ Sex: ____ Birth date: ______________ Address: _________________________ City: _______________________, State: _____ Zip ___________ Parent/Guardian: ______________ Father’s Employer: ____________________________ Mother’s Employer: ___________________________ Additional Cell numbers: ________________________________________________________________ Emergency Contacts: Other than those listed above
Relationship: ____________________________ Relationship: ____________________________ Medical Information
List any allergies (medications, insects, food, etc.) __________________________________________________________________
Date of last Tetanus Booster: _________________________
List any pertinent medical history or health problems: _______________________________________________________________
____________________________________________________________________________________________________________
Operations or serious injuries: ___________________________________________________________________________________
Chronic or recurring illness: ____________________________________________________________________________________
Restricted activities: __________________________________________________________________________________________
Current medications taken and possibly in student’s possession (prescription and non prescription)
____________________________________________________________________________________________________________
_____ I give the School Nurse, or her designee, permission to give over-the-counter medications at her discretion and professional
judgment. I understand the following medications may be on hand: Tylenol, Ibuprofen, Benadryl, Dramamine, Tums, Pepto/Maalox,
Hydrocortisone Cream, Robitussin.
_____ I give the School Nurse, or her designee, permission to only give the listed over the counter medications:
_________________________________________________________________________________________________________
_____ I give the School Nurse, or her designee, permission to give any over-the-counter medications at her discretion and
professional judgment except: ________________________________________________________________________________
_____ I do not give the school nurse or her designee permission to give any over the counter medications to my child.
Medical insurance company: _________________________________ Name of Insured: ______________________________
Policy/Group Number: ___________________________
Parent’s Authorization:
In the event I cannot be reached in an emergency, I hereby authorize the Teays Valley West Middle School
Washington DC chaperones or their designee to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery
for my child as named above. I also authorize release of treatment information to the proper insurance company for payment
purposes.
Parent/Guardian Signature: ____________________________________
Subscribed and sworn before me this _______ day of _______, 20_______ Notary Public ____________________________________ Seal Expires: _______________________________________

Source: https://www.tvsd.us/mw/files/DC_medicatl_authorization_form.pdf

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