2020 ELMS Washington, DC Emergency Medical & Information Form

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Parents - Please fill out this form entirely. Please make only one submission per student.

Email *

Student Last Name *

Student First Name *

Student Middle Name *

Student Date of Birth *

YYYY

Homebase Teacher *

ADULT T-Shirt Size *

Note: T-shirt shirt sizes reflect ADULT T-shirt sizes. Child sizes are unavailable.

Sandwich Preference (if needed) *

If, and only IF, we should need to order a boxed lunch from Subway, which sandwich would your child prefer?

Parent/Legal Guardian Name(s) *

Home Physical Address *

ex: 555 Made Up Lane, Denver, NC 28037

Home Phone # *

Father Alternate # *

Enter Cell or Work # here

Mother Alternate # *

Enter Cell or Work # here

Alternate Emergency Contact Name *

First and Last Name of the person we should contact in the event that the Parent/Legal Guardian is unavailable.

Alt. Emergency Contact Relationship *

Alt. Emergency Contact Phone # *

Physician Name *

Physician Phone # *

Health Insurance? *

Health Insurance Information

Include Insurance Company Name, Subscriber, Subscriber ID, Group Name, Group Number, etc.

Dentist Name *

Dentist Phone *

Dental Insurance *

Dental Insurance Information

Include Subscriber, Subscriber ID, Group Name, Group Number, etc.

Does the student wear contacts? *

Student Allergies *

Indicate all allergies the student may have. If none, please type NONE.

Medical Conditions *

Please list and BRIEFLY describe any medical conditions that administration/chaperones/medical staff should be aware of while on the field trip. If there needs to be a separate, more in-depth conversation about these conditions, please contact Mr. Stamey, Mrs. Spicola or Ms. Bruno to discuss. If none, please type NONE.

Medications *

List any and all medications (Rx and OTC) that your child will need on the field trip. Include the dosage and all instructions for each medicine. IMPORTANT: ALL (Rx and OTC) MEDICATIONS ARE REQUIRED TO HAVE A MEDICAL FORM ON FILE (SIGNED AND COMPLETED BY YOUR MEDICAL DOCTOR) AND BE ADMINISTERED BY AN ELMS STAFF MEMBER. MEDICATIONS SHALL NOT BE IN YOUR CHILD'S POSSESSION AT ANY TIME ON THE FIELD TRIP.

Emergency Treatment Release Statement *

I hereby authorize East Lincoln Middle School Administration or their designee and/or any Licensed Physician, Emergency Medical Technician (EMT) or other qualified hospital/medical personnel to render medical treatment to my son/daughter which, in their judgment, is necessary in the event of illness, injury or medical emergency. I give my permission to refer to the above named persons in the event that my child needs emergency care and I cannot be located immediately. I understand that I am responsible for any expenses that may be incurred in referral or treatment.

Behavior, Conduct and Responsibility Statement *

By selecting YES below, my child and I understand, and will be accountable, for all the information, expectations, guidelines, requirements, deadlines, attending meetings, consequences and policies governing this overnight field trip. All parties understand that major student behavior infractions could be met with removal from the trip at the expense of the parent/legal guardian.

Meeting Notification & Confirmation of Attendance *

By selecting YES below, I am confirming my child and I will be in attendance at the MANDATORY trip meeting on Thursday, March 26, 2020 at 6:30 PM in the ELMS Gymnasium. ALL students attending the trip AND their parent/legal guardian MUST be in attendance. (Please put this in your calendar now. There will be no exceptions to attendance at this meeting. Please plan accordingly NOW!)

A copy of your responses will be emailed to the address you provided.

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