Student Name: ________________________________________


Contact information in case of an emergency:


Name:†† ____________________________________________


Contact numbers: ______________________________________________________


List studentís food and/or medicine allergies:






List any special needs, special instructions, or any other information necessary to properly care for your student:






In the unlikely event of an emergency requiring urgent medical care in your absence, someone will need to be allowed to sign forms to allow treatment.If this is acceptable, please read, sign, and date the statement below.If not, please state on the back of this page what you desire us to do should this unlike situation occur.



I, _____________________________, parent/legal guardian of above-listed student do grant permission for the adults in charge of this trip to sign any necessary medical forms required to render treatment to my child in the unlikely event of a life-threatening emergency.Upon my or another parent/legal guardianís arrival to the medical facility where my child is being treated, all responsibility and decisions shall be deferred back to me or other parent/legal guardian.


______________________________________†††††††††† __________________________

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