Grade 6 Eco-Judaism Trip Medical Form - The Toronto Heschel School

2024 Grade 6 Eco-Judaism Trip Medical Form

Student's Full Legal Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Health Card Number(Required)

Home Phone(Required)

Parent 1 Name(Required)

First Last

Cell Phone(Required)

Work Phone

Parent 2 Name

First Last

Cell Phone

Work Phone

Emergency Contact(Required)

First Last

Relationship(Required)

Cell Phone(Required)

Work Phone

Name of Physician(Required)

First Last

Phone(Required)

List of Daily Medications (Medication must be in their original pharmacy container, bearing the name, dosage, frequency of the drug and patient's name):(Required)

Put N/A if not applicable.

Dietary Restrictions (vegetarian, sensitivities, etc…):(Required)

Put N/A if not applicable.

Allergies (bee stings, medication, food, etc…):(Required)

Put N/A if not applicable.

DOES THE CHILD CARRY AN EPIPEN?(Required)

Yes

(If YES, Please ensure that the child brings 2 unexpired Epipens)

Please check any of the following non-prescription/over the counter drugs that the chaperones have parental/guardian permission to administer if necessary:

Advil

Tylenol

Gravol

Benadryl

Cough Drops

Since this trip involves a great deal of walking, please describe any physical problems or concerns that the chaperones should be aware of:(Required)

Put N/A if no applicable.

IN CASE OF AN EMERGENCY INVOLVING THIS STUDENT AND A PARENT/GUARDIAN CANNOT BE CONTACTED, I AUTHORIZE ANY CHAPERONE ASSOCIATED WITH THIS TRIP TO OBTAIN MINOR MEDICAL CARE FOR MYCHILD.

Parent Signature(Required)

Date(Required)

I/we understand that the school has taken every reasonable precaution to ensure the safety and well-being of my son/daughter and I/we will not hold the school responsible for personal injury, loss or theft. In case of medical emergency and the inability of the school’s designate to contact me, we hereby grant permission to the physician named by the school’s authority to hospitalize, secure proper treatment for and to order injection, anaesthesia, or surgery for my/our child as named below. Our son/daughter agrees to conduct himself/herself according to the rules set out for this trip. We understand that should there be a serious infraction of these rules, the adult chaperones have the right and the responsibility to send our son/daughter home at our expense.

Name of Student(Required)

First Last

Signature(Required)

Date(Required)

Parent/Gaurdian(Required)

First Last

Parent Signature(Required)

Date(Required)

I give _______________ permission to participate on the Grade Six Trip to Camp Gesher on September 11-13, 2024.

First Last

Signature(Required)

Date(Required)