PARENT/GUARDIAN PERMISSION AND
EMERGENCY MEDICAL TREATMENT
AUTHORIZATION/CONSENT FORM
Graduates on Tour 1701 Elsie Park Court Kissimmee, FL 34744
407-870-5666 office
407-870-9348 fax
I, the parent/guardian of _____________________________________________________
LAST
FIRST
M.
Hereby consent for the student above to participate in this trip to: Florida_______
Trip dates(s) April 25 – April 28, 2014 - _______________________________________
By this consent, I hereby release and discharge the school system, the school and all
sponsors from all liabilities, claims, and demands of whatever kind or nature that may
arise or be connected from treatment of my child.
I also understand that if my child becomes a discipline problem while on this trip,
he/she will be sent home by the quickest means and at my expense.
I authorize a chaperone/adult of the school to see that my child receives any emergency
medical treatment that may become reasonably necessary, while said student is on this
trip. Payment of all charges incurred for medical treatment is guaranteed by me or the
insurance company providing coverage for the above named student. Every effort will be
made to contact parents or guardians in advance of treatment, by telephone, in case of
injury or illness.
My child has the following medical problems.
If none, state “none”__________________________________________________________
Treatment for the above_______________________________________________________
My child has the following drug allergies.
If none, state “none” __________________________________________________________
Treatment for allergies________________________________________________________
Please check one of the following:
I do not have medical insurance to cover treatment ____________________________
I have medical insurance with (Policy number)_________________________________
Policy number/Group number________________________________________________
Parent/Guardian (home) _____________________ (work)_________________________
____________________________________
_______________________________________
Mother / Guardian
Father / Guardian
Date ______________
Emergency contact in the event parent/guardian cannot be
reached _________________ phone________________relationship__________________
Witness Notary Public STATE OF________________COUNTY OF_________________
Notary signature_______________________________________________________________