PACIFIC ENVIRONMENTAL EDUCATION CENTER -
HEALTH FORM
Dear Parents: Please carefully read and fill out this form. Each student pariticipating
on this trip must have a completed health form before attending a program at Pacific
Environmental Education Center.
Child's Name_________________________________School______________________________
Home address:_____________________________City:___________________Zip:____________
Home phone: ___________________________Work phone:______________________________
Medical Information
:
1. Does the participant have any severe medical problems? (asthma, allergy to drugs,
heart trouble, epilepsy, diabetes, physical handicaps, or dietary restrictions.)
YES NO
Comments:________________________________________________________________
2. Should there be any limitations on his/her physical activities?
YES NO
Comments:_________________________________________________________________
3. Is the participant taking any medications? YES
NO
Comments:_________________________________________________________________
4. At the present time, is the participant under a doctor's care?
YES NO
Name of doctor:__________________________________phone number:_________________
5. Date of last tetanus booster________________
6. Date of last complete physical examination_____________
7. Name of insurance company______________________________________________
ID #____________________________
8. Circle the following items which may be given to your child (if they ask for it)
by the teacher.
Tylenol Aspirin Motion sickness
pill
As the parent or guardian of _____________________________________I give permission
for my child to attend the field trip to the coast with his/her class on the days
of _____________ to _____________. If I cannot be reached in the case of an emergency
I give permission for my child to be treated by a physician or other emergency personnel.
_________________________________
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