Permission Slip

This is only a SAMPLE

Student Name ________________________________

Grade ____________

Teacher ________________________

School _________________________

For your child to participate in this educational field study, it is necessary for him/her to have your permission and for you to supply certain required information. Please complete the following form and return to school with check or cash by _____________________________.

1. My child has permission to participate in the environmental education field study at Jekyll Island 4-H Center.
Yes ______ No _______

2. My child has permission to participate in all classes chosen by school personnel.
Yes ______ No _______

3. I understand my child must have accidental insurance coverage to attend the trip to Jekyll 4-H. The Jekyll Island 4-H Center is not responsible for medical coverage. The students must be covered by a parent/guardian or school policy.
______ My child is already covered by an insurance policy.

Company Name: ___________________________

Policy No.: _______________________________

______ I will need to purchase a school insurance policy (the school policy with
_________________ costs $ ______).

4. I give permission for my child to be taken to a doctor or hospital for medical treatment should the need arise.
Yes ______ No _______

5. The phone numbers where I can be reached in case of emergency are:
Day #1 _____________________ Day #2_____________________
Evening #1 __________________ Evening #2 __________________
Alternate person if I can’t be reached __________________________
Relationship _________________ Phone # ___________________

6. Special information (allergies, food restrictions, special services required): ______________________________________________________
______________________________________________________

Parent/Guardian Printed Name __________________________

Parent/Guardian Signature ________________________Date ___________

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