Excel Academy Permissions Slip and Authorization Form - MEDICAL

Emergency Medical Information and Consent
Name of Primary Physician

First NameLast Name
Primary Physician Phone Number
Please enter a valid phone number.
Medical Insurance Company
Coverage Number
Known Allergies
Medications Current being Administered (including time and dosage required)
In the event of accident or emergency during or by reason of the field trip when immediate medical care is necessary, I hereby give my consent to the Charter School to authorize any emergency medical treatment or hospital care for my child/student considered necessary on the advice of any physician, surgeon, dentist or
medical care practitioner. It is understood that an effort shall be made to contact the above-listed parent/guardian prior to the rendering of any treatment. It is also understood that an effort shall be made to contact the child’s/student’s physician identified above, but that treatment may be performed by another licensed physician or surgeon, dentist or medical care professional. I, AS THE UNDESIGNED PARENT/GUARDIAN, FULLY UNDERSTANDS I AM FULLY RESPONSIBLE TO PAY ALL COSTS THAT MAY BE INCURRED AS A RESULT OF THE FOREGOING.

If my child is injured at a field trip, I understand that I can contact the Charter School at 949-387-7822

By signing my name below, I hereby acknowledge my intent to sign this Voluntary Field Trip Authorization and Release of Liability, and affirm all of the above.
Parent 1 Signature*

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Parent 2 Signature

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Should be Empty: