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TRAVEL RELEASE AND PARENT PERMISSION/AUTHORIZATION FOR TREATMENT
 
Student Name:_____________________________________________
 
Address:__________________________________________________
 
SSN____________________________ Birthdate_________________
 
If your son/daughter has any particular health problems or allergies,
please describe:
 
 
---------------------------------------------------------------------------------------
 
--------------------------------------------------------------------------------------
 
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Please list the following information pertaining to medical insurance:
 
Name of Insurance Company__________________________________
 
Policy Number_____________________________
 
Policy Holder______________________________________________
 
Names of family to contact in an emergency:
 
__________________________   ______________   ______________
       Name                                         Home Phone           Work Phone
 
__________________________   ______________   ______________
       Name                                         Home Phone           Work Phone
 
Please include the name and phone numbers of persons to contact should
you not be at either of the above numbers:
 
___________________________   ______________   _____________
Name/Relationship to Student              Home Phone         Work Phone
 
___________________________   ______________   _____________
Name/Relationship to Student              Home Phone         Work Phone
 
 
 
                                            TRAVEL RELEASE
 
                I give my consent for this student to represent Monett High School on
activity trips without holding Monett R-1 Schools or trip sponsors responsible
in case of accident or injury.
 
                I give permission for accompanying sponsors to provide or cause to be
provided any emergency medical attention as deemed necessary. I understand
 that I will be notified in the event of any emergency situation as quickly as possible.
 
                This permission and authorization is valid for the period of August 1,
2008 through August 1, 2009
 
 
______________________________    _________________________
Student’s Signature                                 Parent or Guardian Signature
 
 
Date_________________________
 
 
    This page must be returned to the principal’s office.
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