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Consent to Treatment Form- Field Trip/Off Campus
PERMISSION/CONSENT TO TREATMENT
AND HEALTH INSURANCE INFORMATION
(Off Campus – take on trip)
Wisconsin Conference of Seventh-day Adventists ____________________________________
We/I, the undersigned parents or guardian of __________________________________ a minor, do hereby give
our/my permission/consent for the above named child to participate in the following school sponsored activity:
_______________________________________ to be held at _______________________________________,
on the dates of ______________________ between the hours of _____________ and _______________.
We/I are/am aware that by our/my child participating in this activity there is the possibility there may occur a need for emergency medical treatment as a result of accident or sickness.
In the event emergency medical treatment becomes necessary for my child, we/I grant to ________________
Teacher or Director
or their assistants authority to obtain such emergency medical assistance.
____We/I further grant to the medical care provider the authority and permission to administer emergency medical treatment.
____We/I consent to my child being transported to/from the above stated activity premises by private car, church/school owned bus or other means, for the purpose of the above state activity.
Drivers: ______________________ ______________________
____We/I understand the school will supply no transportation. Each child is responsible for their own transportation to and from the above stated activity.
This permission/consent shall remain in continuous effect until revoked in writing and delivered to the above named teacher/director or to the person entrusted with the custody of said minor.
The above named minor is ___, is not ___ covered by health insurance.
Present Health Insurance Company _______________________ Policy Number ________________________
Signature of Father Date
Signature of Mother Date
Signature of Guardian Date
Parents Names: _______________________________________
Phone – Father - home ( )____________ work ( )______________ Cell ( )____________
Phone – Mother - home ( )____________ work ( )______________ Cell ( )____________
C:\Documents and Settings\Owner\My Documents\Red Book\Consent to treat off campus.doc