Parent/Legal Guardian Authorization for
Student Participation and Travel
This completed form and payment (if applicable) are due on or before:
_____________________________ to ____________________________________________________________.
(Date) |
(Advisor/Teacher) |
Permission is requested for your child to participate in the following: |
Activity: _____________________________________ |
School: _____________________________________ |
Organization: ________________________________ |
Place: ______________________________________ |
Teacher/Advisor: _____________________________ |
Dates: ___________________ Times: ____________ |
Mode of Transportation: ______________________ |
a. Transportation... ($ __________ ) |
|
b. Entrance Fee..... ($ __________ ) |
|
c. Other Costs....... ($ __________ ) |
|
d. Total Cost.......... ($ |
__________ |
) |
Parental Permission
(To be completed by Parent/Legal Guardian)
Name of Student: _________________________________________________ Home Phone: _____________
Emergency Contact: ____________________________________________________ Phone: _____________
Check as appropriate: |
(Please include relationship) |
|
My son/daughter has permission to attend the above activity.
My son/daughter DOES NOT have permission to attend the above activity.
Medical Insurance Coverage
My child has medical coverage with: _______________________________________________________
(Name of plan, e.g., HMSA, Kaiser, Military, etc.)
My child is not covered by any medical insurance plan.
Private Vehicle Usage
My son/daughter may drive to the activity alone. (Form BO-4, “Application for Use of Private Vehicle to Transport Students” must be completed and attached to this form.)
My son/daughter may ride in a vehicle driven by an adult to the activity.
Igrant permission for the above named student to participate in the activity/activities listed above, and to travel by private or commercial car, bus, train, airplane, and other means of transportation as required.
Ifurther give permission to travel by the mode indicated above. I release the State from liability resulting from the use of other than school vehicles pursuant to HRS 286-181.
In the case of illness or injury to above named student, I hereby consent to and authorize such treatment as deemed necessary, and agree to pay for such medical and dental costs if incurred.
_____________________________________________________________
Print or Type Parent’s/Legal Guardian’s Name |
|
_____________________________________________________________ |
__________________________ |
Parent’s/Legal Guardian’s Signature |
Date |
Teacher Acknowledgment for Student Travel (To be completed by subject teachers, if applicable)
Please sign below to acknowledge that the above student will be missing class because of the activity mentioned above. He/She understands that all class work shall be made up at YOUR convenience.
Home Room: _______________________________ Period 4: ___________________________________
Period 1: ___________________________________ Period 5: ___________________________________
Period 2: ___________________________________ Period 6: ___________________________________
Period 3: ___________________________________ Period 7: ___________________________________
