Parent's Consent and Authorization For Travel and Emergency Medical Form

Parent's Consent and Authorization For Travel and Emergency Medical Form
This form lets parents and guardians complete the entire form online. After filling it out, the form must be printed and submitted to the student's school.
Parent/Guardian Name

First NameLast Name
Student Name

First NameLast Name
Parent/Guardian Name
First Name, Last Name
Student Name
First Name, Last Name
I, {parentguardianName} , the parent / guardian of {studentName} do hereby provide my consent and authorization for my child to travel with the following travel group sponsored by the Harrison County Board of Education
Student's Current School
Student's Current Grade

Student Medical Information
Is student allergic to anything?

YesNo
If yes, please explain
Will the student need to take ANY (over the counter or prescribed) medications while on this ﬁeld trip?

YesNo
If yes, please explain
Family Physician:
Physician Office Phone Number:
Instructions for emergency medical treatment:

For the Parent / Guardian:
I hereby grant permission for the above to participate in this curricular, co-curricular, or extra-curricular activity. In the event of an accident or medical illness, permission is granted for any such medical and/or surgical treatment as may be necessary. Every eﬀort will be made to notify me before any major treatment is undertaken.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Trip Information