Butler Gettysburg Signup Form Placeholder

Medical Information

Insurance

Company Policy # Group #

Policyholder Name

First Last

Family Physician

Name Phone

Over-the-Counter Medications

This student has permission to take the following medicine if needed during the field trip. He or she must ask a sponsoring teacher and will be given the medication under a chaperone's supervision. Students should not bring any of these OTC medications - we will provide them.

Acetaminophen
Antacid (Tums)
Immodium
Ibuprofen
Benadryl
Dramamine

Conditions

Has the student had any of the following? (check all that apply).

Additional Info

If you checked 'yes' to any of the above conditions, or if there is another condition we should know about, please provide additional information.

Tetanus*

Is this student's tetanus immunization current?

Yes
No
Unknown

Known Allergies*

Yes
No

*

List all allergies and any medication in case of exposure and/or steps of action

Prescription Medications*

Will this student require any prescription medications during the field trip? (Note: be aware that sustained focus and impulse control is needed at most of our stops, just like it is in class.)

Yes
No

*

Please list the exact medicine including strength, reason for taking, and directions for dosing.

Students are not permitted to have any medications in their possession during the field trip. If your student needs medication:

Parents or guardians should give medication to the bus chaperone on the morning of the trip.
Medications must be in the original container with the student's name, dosing information, and any additional information on the label.
Send only the amount that the student will need during the trip

If there are any additional circumstances of which the tour coordinator or bus chaperones should be aware, medical or otherwise, please contact Rebecca Green from Logan Tours, at 724. 355. 4997 or logantoursinc@gmail.com All medical and other information is treated with strict confidentiality and only the chaperones who are with your child will be made aware of information needed to keep your child safe.

Medication Information Confirmation

Please check the box next to each paragraph to mark as read.

*

As the parent(s)/guardian(s) of the above-named student, I/we on behalf of myself/ourselves, my/our heirs, executors, administrators, and assigns, and on behalf of the above-named student do hereby release and discharge Logan Tours, Inc., their employees, agents, and/or servants from any and all rights, claims, and/or actions which I/we and/or the above named student may hereafter have against Logan Tours, Inc. their employees, agents and/or servants arising out of the aforementioned field trip. I understand that in the case of a medical emergency, every reasonable attempt will be made to contact the parent(s)/guardian(s) of the above-named student. If, however, I/we cannot be contacted and a medical emergency arises; I/we by affixing my/our signature(s) to this form give permission for my/our child to receive all necessary emergency medical care. I understand that if my child takes a daily medication at school or has emergency medication at school (bee sting or inhaler), the principal’s designee (teacher or other staff person) will dispense this medication during the field trip.

*

I, the parent/guardian, do hereby release, discharge, and hold harmless Butler Area School District and Logan Tours, Inc. their agents and employees, from any and all liabilities, and claim whatsoever for the administration of the above medication to my child/ward should there develop an allergic or other reaction from the medication.

Parent/Guardian Signature*

Butler Gettysburg Trip: SIGN UP

What You'll Need

STUDENT INFORMATION

Butler Area School District Release of Liability and Hold Harmless Agreement

Medical Information

Medication Information Confirmation

Permission to Photograph, Discipline, and Tobacco Policies