PARENT PERMISSION FORM
ST. JAMES CATHOLIC SCHOOL
830-379-2878
Keeping God In Everything We Do.
Type of Transportation: ______________ Time of Departure: ________ Approx. Time of Return: ___________
#
of Chaperones: ___ Names:
__________________________________________________________
__________________________________________________________
Each
child will need:
Expenses: ___________________________________________________________________ Clothing:
___________________________________________________________________ Equipment:
_________________________________________________________________
Activity
Planned: __________________________________________________________________
IN CASE OF EMERGENCY, THE TEACHER WILL IMMEDIATELY CONTACT THE PARENTS OR OTHER AUTHORIZED PERSONS LISTED BELOW. IN THE EVENT OF A SERIOUS INJURY THE TEACHER WILL SEEK THE NEAREST MEDICAL FACILITY UNLESS OTHERWISE NOTED.
(Teacher)
______________________________________
----------------------------------------------------------------------------------------------------------------------------
[CUT AT DOTTED LINE. KEEP TOP PORTION FOR REFERENCE AND RETURN
BOTTOM PORTION TO THE SCHOOL.]
(Name) (Activity)
· He/She is in good physical condition and has not had any serious illness since his/her last medical examination.
(No, explain): ___________________________________________________________ (Yes) ______________
· Any medical considerations (allergies, medications, etc.) (Yes, specify): ____________________________(No)_____
·
ANY ACTIVITIES NEAR OR AROUND WATER (INCLUDING
SWIMMING):
· My child ___ (IS) ___ (IS NOT) a competent swimmer and I request that he/she ___ (BE ALLOWED) ___ (NOT BE ALLOWED) to participate in any water activities.
If I cannot be reached in the event of an emergency, the
following persons are authorized to act on my behalf:
1. _____________________________________ 2. ______________________________________
Phone: _______________________________ Phone: ________________________________
If neither I nor the authorized persons listed above can be contacted in the event of an emergency, I authorize the adults in charge to contact a physician, even if such treatment is not covered by the school accident insurance.
Name of Physician and/or hospital preferred:
_______________________________________________________
Phone: _____________________
___
Yes ____ No Seek nearest medical
facility if time & seriousness of the injury are a factor.
DATE:
____________ PARENT OR GUARDIAN:
________________________________________