GREATER ESSEX COUNTY DISTRICT SCHOOL BOARD

MEDICAL CONSENT FORM

FIELD TRIP / ATHLETIC EVENT

This form is important. Please get it translated if you do not understand it.
Note:

STUDENTS UNDER 18 YEARS Form to be signed by parent/guardian

STUDENTS 18 YEARS OR OLDER Form to be signed by student

I, the parent/guardian of _______________________________________________________ hereby consent to

(print name)

my son/daughter/ward participating in the following field trip/athletic event:

Event: _______________________________________________

Date: _______________________________

Should it become necessary for my child to have medical care, I hereby give the teacher supervisor permission to
use his/her best judgment in obtaining the best of such service for my son/daughter/ward.
I understand that in the event of illness or accident, I will be notified as soon as possible.
I also understand that out-of-country health insurance is required when students are involved in an out-of-country
field trip or athletic event.
Parent/Guardian Signature
(For Student under 18 years): _________________________________

Date: ________________________

Name of Parent/Guardian (please print): _________________________________________________________

OR
Student Signature
(Student 18 years or older): ___________________________________

Date: ________________________

MEDICAL INFORMATION REQUIRED

Health Card #: _______________________________ Date of Birth: _________________________________
Out-of-Country Health Insurance (required for out-of-country field trips/athletic events only):
Company: __________________________________ Policy Number:

_______________________________

Family Doctor: _______________________________ Phone Number: _______________________________

List Drug Allergies: _________________________________________________________________________
________________________________________________________________________________________________________________

List medical conditions or diseases staff should be aware of: _____________________________________

__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________

List medications student will be taking on the trip (prescription medication should be in the original container
with prescription details listed):
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________

Name, address and phone number of two persons who may be contacted in case of emergency:
Name: _____________________________________ Name:

______________________________________

Address: ___________________________________ Address: _____________________________________

Day phone number:

__________________________ Day phone number: ____________________________

Night phone number:

_________________________ Night phone number: ___________________________

Please see important information on Page 2.

September 10, 2012

MEDICAL CONSENT FORM

AP-BA-21 Form 3 / Page 1 of 2

GREATER ESSEX COUNTY DISTRICT SCHOOL BOARD

MEDICAL CONSENT FORM
FIELD TRIP / ATHLETIC EVENT

This form is important. Please get it translated if you do not understand it.
This information is collected pursuant to the Greater Essex County District School Board Privacy
Policy and Regulation HR-14 as set out in the Education Act and its regulations. This information will
become part of the Ontario Student Record (OSR) and opportunities will be provided to update this
information annually.
This information is collected for educational, transportation and safety purposes and is within
guidelines set out in the Municipal Freedom of Information and Protection of Privacy Act, 1989.
Select information will be shared as required and will be used for educational purposes for planning
and programming, and to assist with transitions into secondary school.
Any questions with respect to this information should be directed to the Principal of the school in
which the student is applying and or registered.

Health information will be released to the Local Health Unit as required by law and in the case of an
emergency, to the hospital or health officials as required. (Note: Under the Immunization for
School Pupils Act, 1982, every child who goes to school in Ontario must provide proof of
immunization, or file the appropriate exemption with the medical officer of health. The Public Health
Division is required by law to keep immunization records on every student.) Telephone numbers
may be released to school board employees for emergency response issues.
The information on this form is collected under the legal authority of the Ministry of Education Act,
R.S.O. 1990 and is used for the administration and statistical purposes of the Greater Essex County
District School Board.

September 10, 2012

MEDICAL CONSENT FORM

AP-BA-21 Form 3 / Page 2 of 2