N a m e of stu d e nt:
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PARENTAL PERMISSION
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c h o ol
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c h o ol Ph o n e G r a d e /
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o o m D a t e Pr e p a r e d
T e a c h er D e sti n a ti o n
Ed u c a ti o n a l Purp ose of Tri p
D a t e of Tri p Tri p Itin er ary (su m m a ry)
M e th o d of Tr a ns p ort a tio n C ost t o
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tu d e nt
I un d erst a n d th a t in c as e of a ny e m er g e n c y r e q uirin g m e di c al tr e a t m e nt, e v ery e ffort will b e m a d e t o r e a c h
o n e of th e p e o pl e list e d a b o v e . If n o n e of th es e p e o pl e c a n b e c o nt a ct e d , I a uth oriz e th e s c h o ol t o giv e
c o ns e nt t o tr e a tm e nt a s d e e m e d n e c ess ary b y e m er g e n c y r es p o n d ers.
Print N a m e of P a r e nt/s or G u a r di a n /s:
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i g n a tur e of P ar e nt/s or G u a r di a n /s: D a t e :
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A copy of this for m is to b e ke pt on file until the end of the school ye ar.
Brin gFr e e Bu y$____ ___ Pr o vi d e d
TRIP INF ORMATI ON
STUDENT INFORMATION
I. D .#: D a t e o f Birth:
PARENT / GUARDIAN INF ORMATION
S
tu d e nt liv es with ( c h e ck a ll th a t a p pli es): F a th er M oth er G u a r d i a n
EMERGENCY C ONTACTS
If th e p ar e nts/ g u a r di a ns c a nn ot b e r e a c h e d, th e s c h o ol wi ll c all th e p e o p l e list e d b e l o w. Th e p e o pl e list e d
b e l o w sho ul d b e r es p o nsi b l e in divid u a ls w h o c a n: 1) giv e p e r missio n to a d minist er h e alth c ar e ; 2) pi c k u p yo ur
c hil d if yo ur c hil d is ill; 3) h a v e th e a uth ority t o s p e a k o n b e h a lf of th e p a r e nts or l e g a l g u a r di a ns.
HEALTH INFORMATION
I f p e r missio n is gr a nt e d , pl e as e pro vi d e th e f ollo win g m e d i c al inf orm a ti o n or if yo ur c hil d d o es n ot h a v e a ny of
th e h e a lth c o n diti o ns list e d b e l o w , pl e as e writ e
“ n o n e ”
.
Physi c i a n ’s N a m e : Pho n e:
M e di c a l / Hos p it a l Insur a n c e : G r o u p: Ty p e:
M e di c a tio n /s b ein g t a k e n b y stu d e nt:
All er gi es to f o o ds, dr inks, ins e ct bit es, m e di c a tio ns, oth er:
O th er m e di c a l infor m a ti o n:
I have re a d the trip infor mation to:
Pl e as e c o m p l e t e a n d d e t a c h th e b otto m p a rt of this f or m a n d r e turn t o t e a c h e r
N a m e:
Ho m e Pho n e :
W ork Pho n e:
C ell Ph o n e :
EH-80 P a r e nt a l P e r missi on (
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N a m e:
Ho m e Pho n e :
W ork Pho n e:
C ell Ph o n e :
Che ck one: my child
on
may
1. P a r e nt / G u ar di a n: Ho m e A d dr ess:Ho m e A d dr ess:
W ork Ph o n e : C ell Ph o n e :Ho m e Pho n e :
2. P a r e nt / G u ar di a n: Ho m e A d dr ess:Ho m e A d dr ess:
W ork Ph o n e : C ell Ph o n e :Ho m e Pho n e :
.
ma y not go on this trip
N ot N e e d e d
