2023 Grade 6 Eco-Judaism Trip Form

Student's Full Legal Name(Required)
Address(Required)
MM slash DD slash YYYY
Parent 1 Name(Required)
Parent 2 Name
Emergency Contact(Required)
Name of Physician(Required)
Put N/A if not applicable.
Put N/A if not applicable.
Put N/A if not applicable.
DOES THE CHILD CARRY AN EPIPEN?(Required)
Please check any of the following non-prescription/over the counter drugs that the chaperones have parental/guardian permission to administer if necessary:
Put N/A if no applicable.
I/we understand that the school has taken every reasonable precaution to ensure the safety and well-being of my/our child and I/we will not hold the school responsible for personal injury, loss or theft. In case of medical emergency and the inability of the school’s designate to contact me, we hereby grant permission to the physician named by the school’s authority to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery for my/our child as named below.
Name of Student(Required)
MM slash DD slash YYYY
IN CASE OF AN EMERGENCY INVOLVING THIS STUDENT AND A PARENT/GUARDIAN CANNOT BE CONTACTED, I AUTHORIZE ANY CHAPERONE ASSOCIATED WITH THIS TRIP TO OBTAIN MINOR MEDICAL CARE FOR MY CHILD.
MM slash DD slash YYYY
Additionally, my/our child agrees to conduct themselves according to the rules set out for this trip. We understand that should there be a serious infraction of these rules, the adult chaperones have the right and the responsibility to send our child home at our expense.
Parent/Guardian Name(Required)
MM slash DD slash YYYY
Student Name(Required)
MM slash DD slash YYYY
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