Dubuque Senior High School Music Department
Permission/Consent for DSHS Music Department 2013-2014
I am the person legally responsible for_____________________________________________________________.
Birth Date:___________ Address:________________________________________________________________
Parent/Gaurdian Name ________________________________________________________________________
Home Phone: ____________________________
Emergency Phone: ________________________________
Optional People to contact in case of emergency:
Name ___________________________________ Phone No. ______________________
Name ___________________________________ Phone No. ______________________
Does your child have any medical condition or is he/she under medication that we should know of? No ___ Yes ___
If yes, please explain
____________________________________________________________________________________________
____________________________________________________________________________________________
Student’s Blood Type ___________________ Allergies _______________________________________________
Insurance Co. ___________________________________ Policy Number _________________________________
Insurance Co. Address __________________________________________________________________________
Doctor’s Name ____________________________ Office Phone No. _____________________________________
In the event of a medical emergency, I authorize the school sponsor to make the necessary decisions for the safety of
my child’s health.
Parent’s or Guardian’s Signature ______________________________________________________________
Student’s Signature _________________________________________________________________________
Date __________
I hereby give her/him permission to travel with the Dubuque Senior High School Music Department for the
2013-2104 school year. I also give all trip personnel permission to provide medical treatment to my child in the case
of an emergency. It is understood that all Dubuque Senior High School policies will be in effect for the duration of
any trip including the DSHS Student Good Conduct policy. Tri-State Tours will act only as an agent for our tour
members in arranging hotel rooms and changes in the itinerary as circumstances dictate. Tri-State Tours, Dubuque
Senior High School, or the music directors are not responsible to any person for the loss of time, money, or personal
belongings.
I understand that any infraction of Dubuque Senior High School rules, the Student Good Conduct
Code, or trip rules could result in my child being sent home at my expense. I also understand that the trip
personnel will make every possible effort to contact me and inform me of the situation before any such action
is taken.
As a participant on any school trip, I agree to all terms, conditions, and rules of DSHS, Student Code
of Conduct, and all trip rules. I realize that if I break this contract that I may be in jeopardy of sanctions
leveled against me including but not limited to: being denied admission the event or sight seeing activities, or
being sent home at my or my parent’s expense, or being expelled from future extra-curricular activities in
accordance with Iowa High School Music Association guidelines and Dubuque Community School District
policy.