Joshua Springs Calvary Chapel and Christian School

57373Joshua Lane

Yucca Valley, CA 92284

Permission Slip

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Destination: ________________________________________________________________

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Date of Trip: ________________________________________________________________

Time Leaving:________________________ Time Returning:___________________________

Cost of Trip $_________________________

Emergency Information

Student’s Name_______________________ Birthday___________ Grade____

Home Phone # ____________________________

Home Address __________________________________ City____________________Zip_____

Father’s Work # _____________________ Father’s Cell/Pager #_________________

Mother’s Work # _____________________ Mother’s Cell/Pager #_________________

Emergency Contact Name___________________________ Phone #_____________

(If parents are unreachable)

Health Insurance Carrier_____________________________Policy #______________

Physician’s Name_________________________________ Phone #______________

Any Restictions?_____________________Allergies?____________Taking Medications?_______

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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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