Emergency Data Sheet - Warriors worldwide



Italy Spring Break Trip - Emergency Data Sheet

Student Name _____________________________Date of Birth ________________

Parent(s) name(s)_______________________________________________________

Address: _____________________________________________________________

Home Phone ___________________Cell Phone(s) ______________________

Work Phone (m)_________________Work Phone (d)____________________

*Star the phone number you would like included in an emergency phone tree list.

Where would you like the number to be placed on the phone tree? (People near the top should be available to make additional phone calls.)

Top ______ Middle _______ Bottom ______ Please do not include me _______

Preferred Email: _________________________________________________

In the event a parent cannot be reached, please call:

1. ____________________________phone # __________________

2. ____________________________phone # __________________

Medical Information:

|Family Physician (name and | |

|number) | |

|Insurance carrier (name, phone, | |

|and policy number) | |

|Allergies or other medical | |

|concerns | |

| | |

| | |

|Over-the-Counter Medicine allowed| |

|(Advil, Sudafed, Tums, etc.) | |

|Prescription Medicine being used | |

|currently – Please include | |

|dosage/frequency | |

|Other Dietary considerations | |

|(vegan, vegetarian, etc.) | |

Authorization to Consent for Emergency Treatment

I, the undersigned, parent or legal guardian of _____________________________ (student name), do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment that is deemed advisable by and is to be rendered under the general supervision of a physician or surgeon.

It is understood that this authorization is given in advance of any specific diagnosis of treatment being required. It is given to provide specific consent to any and all such diagnosis treatment that the aforementioned physician or surgeon in the exercise of his/her judgment may deem advisable and neither the physician, surgeon, or any organization or group leaders involved assumes any financial responsibility for acting under the authority granted by this consent.

Print legal parent or guardian name

__________________________________________________________________________

Parent or legal guardian signature Date

Trip Policies

I have read the Italy Spring Break Trip Policies and my signature below signifies that I support the regulations. I also understand that if a student violates any policy, they may be dismissed from the tour immediately and sent home at their own expense.

Student Signature _____________________________Date ______________

Parent Signature ______________________________Date ______________

Authorization to Travel – Parental Consent Letter

Customs and Border Protection

I, the undersigned, parent or legal guardian of _____________________________ (student name), do hereby consent to allow my child to travel to Europe with Elizabeth Mulcahy and Sandra (Lani) Hoza from March 30-April 6, 2017. This is part of a high school student educational trip to Italy.

Print legal parent or guardian name

__________________________________________________________________________

Parent or legal guardian signature Date

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