Parental Permission
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1THE SCHOOL DISTRICT OF PHILADELPHIA
PARENTAL PERMISSION
TRIP INFORMATION
School
School Phone
Grade/Room
Date Prepared
Teacher
Destination
Educational Purpose of Trip
Date of Trip
Leave Time
Return Time
Trip Itinerary (summary)
Method of Transportation
Cost to Student
Student Lunch
Free
$_______
Bring
Buy
Provided
Not Needed
Please complete and detach the bottom part of this form and return to teacher
STUDENT INFORMATION
Name of student:
I.D.#:
Date of Birth:
PARENT/GUARDIAN INFORMATION
1. Parent/Guardian:
Home Address:
Home Address:
Home Phone:
Work Phone:
Cell Phone:
2. Parent/Guardian:
Home Address:
Home Address:
Home Phone:
Work Phone:
Cell Phone:
Student lives with (check all that applies):
Father
Mother
Guardian
EMERGENCY CONTACTS
If the parents/guardians cannot be reached, the school will call the people listed below. The people listed
below should be responsible individuals who can: 1) give permission to administer health care; 2) pick up your
child if your child is ill; 3) have the authority to speak on behalf of the parents or legal guardians.
Name:
Name:
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Cell Phone:
Cell Phone:
HEALTH INFORMATION
If permission is granted, please provide the following medical information or if your child does not have any of
the health conditions listed below, please write “none”.
Medication/s being taken by student:
Allergies to foods, drinks, insect bites, medications, other:
Other medical information:
Physician’s Name:
Phone:
Medical/Hospital Insurance:
Group:
Type:
.
I have read the trip information to:
on
Check one: my child
may
may not
go on this trip
I understand that in case of any emergency requiring medical treatment, every effort will be made to reach
one of the people listed above. If none of these people can be contacted, I authorize the school to give
consent to treatment as deemed necessary by emergency responders.
Print Name of Parent/s or Guardian/s:
Signature of Parent/s or Guardian/s:
Date:
A copy of this form is to be kept on file until the end of the school year.
EH-80 Parental Permission (Rev. 10/06) - THE SCHOOL DISTRICT OF PHILADELPHIA
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