Please print and complete
This Document MUST be complete AND notarized with deposit
Personal Information Name ______________________ Date of Birth - ________________ Address_ ____________________ ____________________________ Phone - _____________________ Cell _________________________ Emergency Contact Name _______________________ Relationship __________________ Phone _______________________ Alternate phone number ____________________________ Medical and Insurance Information Insurance Co: ___________________ Policy # ________________________ Family Physician:____________________________ Phone: ____________________________________ Permission I, ______________________ (parent/guardian), hereby give permission for _____________________________ to travel with ______________________ to ______________________ during the following dates _____________________. I do hereby verify that the information below is correct and grant permission to : 1. _______________________________ 2. _______________________________ to obtain medical attention in case of sickness or injury to my child. I hereby grant permission for an attending physician or hospital to perform whatever care deemed necessary for the welfare of my child until you are able to reach me personally - Signature of Parent ____________________________________ Date ___________________________________ Phone __________________________________ Cell _____________________________________ | Check applicable spaces and give appropriate information below: Allergies_________ Insects__________ Medicines________ Asthma__________ Bronchitis________ Diabetes_________ Dizziness________ Heart Trouble__________ Kidney Trouble__________ Sinusitis_________ Stomach Upset___________ Other ________________ Immunizations Tetanus: Date received ________________ List any prescription drugs the student will be taking while on trip; state frequency and dosage for each. _____________________ ____________________ Notary On this ______ day of _______________, 20__, ________________________ (parent/guardian) personally appeared before me in ________________ County, in the state of Indana, and in my presence executed the within and foregoing permission and release form. Witness my hand and official seal this _____ day of _______________, 20__. My commission expires _______________________. Signature Notary Public ________________________. |