Joshua Springs Calvary Chapel and Christian School

57373Joshua Lane

Yucca Valley, CA  92284

 

Cyber Permission Slip

 

  1. Copy this blank Word document to your computer.
  2. Complete the document and save it on your computer.
  3. Print the document and submit it to the trip organizer.
  4. For the next trip, change any info that needs to be changed and then print.

 

Trip Information

 

Destination:

Date of Trip:

Time Leaving:

Time Returning:

Cost:

 

 


Emergency Information

 

Student’s Name:

Birthday:

Grade:

Home Phone:

Home Address:

Home City:

Home Zip:

Father’s Work Phone #:

Father’s Cell/Pager #:

Mother’s Work Phone #:

Mother’s Cell/Pager #

Emergency Contact Name if parent is unreachable:

Emergency Contact Phone #:

Health Insurance Carrier:

Policy #:

Physician’s name:

Physician’s phone number:

Any restrictions?             

Allergies?

Taking Medications?

 

I, the undersigned parent, give authorization and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered as necessary by a qualified member of the medical staff of a licensed hospital.  It is understood that all efforts will be made to contact me prior to rendering treatment, but treatment will not be withheld if I cannot be reached.  I will not hold Joshua Springs Christian School, its employees, officers or agents responsible in the case of any accidents.

 

Parent Signature___________________________________________________

 

 

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