Education Service Center Region 12-Waco-UB-Field Trip Form

UPWARD BOUND FIELD TRIP

Authorization for Student Participation
THIS FORM COVERS ALL FIELD TRIPS FROM

September 1, 2021 - August 31, 2022

** Parents, please complete all of the following information**
Student's Name *

First Name Last Name
Name of Parent/Guardian

First Name Last Name
Email *
example@example.com
Phone Number
(999)999-9999
A. Parent/Guardian Information

I understand that my son/daughter is not required to attend this ESC Region 12 field trip. I give permission for participation in the activity. I agree to release Education Service Center Region 12 and its officials, officers, and employees from liability for any and all claims of injury which might occur while my son/daughter is participating in this field trip activity.

B. Emergency Medical Authorization

Should a medical emergency arise while my son/daughter is participating in this activity, I will be notified at the above number in order to approve medical treatment. In the event that I or one of the emergency contacts listed below cannot be reached, I give permission for immediate treatment as required in the judgment of the attending physician. I understand and agree that I will be responsible for the cost of such treatment.
Emergency Contact

First Name Last Name
Phone Number
(999)999-9999
Emergency Contact

First Name Last Name
Phone Number
(999)999-9999
Name of Insurance Company
Group/Policy Number
Allergies/Special Health Considerations
Signature of Parent/Guardian *

Clear
Date Signed

Month Day Year
mm-dd-yyyy

UPWARD BOUND FIELD TRIP