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PERMISSION FORM
FOR
ENVIRONMENTAL EDUCATION FIELD TRIP
WAHSEGA 4-H CENTER
In order for your child to participate in this environmental education field trip, it will be necessary for him/her to obtain permission of a parent or guardian by having this form completed.
My child, ___________________________________________, has permission to participate in the environmental education field trip to the Wahsega 4-H Center in Dahlonega, Georgia on __________ 2004. I understand that the information in the next section must be complete.
___________________________________________
(Parent or Guardian Signature)
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I understand that for my child to participate in this field trip that he/she must have accidental insurance coverage. This coverage may either be under an individual family policy or under a 24-hour school policy. Please check and complete one of the following:
_____A. My child, ____________________, will be covered under an individual family
policy.
Insurance Company Name _______________________________________________
Insurance Policy Number ________________________________________________
Insurance Company Number _____________________________________________
Ins. Company Address __________________________________________________
_____B. My child, ____________________, will be covered under a 24-hour school
policy.
Policy Number _________________________________________________________
Company Name_________________________________________________________
__________________________________________
(Parent or Guardian Signature)
Permission for Medical Treatment
In the event of an emergency requiring medical attention, I hereby grant permission to a physician, dentist, or other hospital personnel designated by the Arnall Middle School Staff to attend my son/daughter. I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken.
Signature______________________________________________________________
Address_______________________________________________________________
Home Phone _________________________________ Business Phone _______________
Facts concerning the child's medical history including allergies, medications being taken, and any physical impairments to which medical personnel should be alerted are:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Any medication which should be taken during the field trip should be given to your team leader no later than the morning you leave for camp, along with a note from parent/guardian explaining dosage and other pertinent information.
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