Field Trip Permission Form Gordon County Schools PO Box 12001 Calhoun GA 30703-12001 _______

School: ___ Grade: ____ Teacher: _ Phone: _

Date: Destination: ______________________________________________________________________

Time of Departure: Time of Return: _ Please return permission slip by: _______________________

Fee Required: Yes No Amount: (Exact cash or check made payable to the school)

Emergency Contact and Medical Information

_____________________________________________________ ___________________________ Male Female Student’s Name Date of Birth Sex

_____________________________________________________ ___________________________________________ Parent/Guardian Parent/Guardian

________________________ ____________________ _______________________ ___________________ Home Phone Work or Cell Phone Home Phone Work or Cell Phone

Alternative Emergency Contacts

_____________________________________________________ ___________________________________________ Primary Emergency Contact Secondary Emergency Contact

________________________ ____________________ _______________________ ___________________ Home Phone Work or Cell Phone Home Phone Work or Cell Phone

Medical Information

________________________________________________________________________________________________________________________ Hospital / Clinic Preference

_____________________________________________________ __________________________________________ Physician’s Name Phone Number

_____________________________________________________ __________________________________________ Insurance Company Policy Number

________________________________________________________________________________________________________________________ Allergies / Special Health Considerations / Medications I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

________________________________________________ __________________________________________________ Parent/Guardian Signature Date I give my permission for my child to attend the field trip destination listed above. I release the Gordon County Board of Education, its employees and volunteers from liability in case of accident during activities related to this field trip as long as normal safety procedures have been taken.

________________________________________________ __________________________________________________ Parent/Guardian Signature Date

_______ Yes, I am interested in attending the field trip as a chaperone. Please contact me at ________________________ to confirm. Phone