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