PARENTAL CONSENT FOR TRIP SPONSORED BY McDONOUGH HIGH SCHOOL
(Last) (First) (Middle)
Teacher, Coach, Sponsor: ___________________________ Mode of Transportation: _________________
Time of Departure: ____________ Time of Return: ______________ Cost per Pupil: ________________
Purpose of Field Trip: ______________________________________________________________________
EMERGENCY MEDICAL/CONTACT INFORMATION
(Please Print)
Parent/Guardian Names: ____________________________ Home Phone # (______)___________________
Address: __________________________________________ Mother’s Work # (______)________________
__________________________________________________ Cell #(______)___________________________
Date of Birth ___________Grade_________ Age_________ Pager# (______)_________________________
Father’s Work # (______)________________
Family Doctor: _____________________________________ Cell # (________) _______________________
Doctor’s Phone # (_______)___________________________ Pager # (______) _______________________
List two neighbors or nearby relatives who have your permission to assume temporary care of your child if you cannot be reached.
Name: ______________________________________________ Phone # (________)_________________________
Address:_____________________________________________ Work # (_______)__________________________
Name: ______________________________________________ Phone # (_______)__________________________
Address:_____________________________________________ Work # (_______)__________________________
In case of an accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school representative to arrange transportation to and treatment of my child at the emergency room of the nearest hospital, or if outside the country, to the nearest facility where medical treatment is available.
List any allergies that your student has: _______________________________________________________________
List any medical conditions the school needs to be aware of: ______________________________________________
List medications that your student takes on a regular basis: _______________________________________________
Medical Insurance Carrier/Company: _______________________________ Policy #__________________________
PARENTAL/GUARDIAN CONSENT
I hereby give my consent for the above arrangements.
Parent/Guardian Signature:___________________________________ Date:_________________________
(Please Print Name:__________________________________________
Student’s Name:_____________________ __________________ ___________ Date of Trip: __________
