EMERGENCY INFORMATION AND TRIP CONSENT
Child's Name: __________________________________________________________
Address: __________________________________________________________
1st ____________________________________ ____________________ ________
name number type (cell, work, home, etc.)
2nd ____________________________________ ____________________ ________
name number type (cell, work, home, etc.)
3rd ____________________________________ ____________________ ________
name number type (cell, work, home, etc.)
4th ____________________________________ ____________________ ________
name number type (cell, work, home, etc.)
My child, _____________________________________________, has permission to go on a 3 day
weekend ski trip with Robert Carr on January 28-31, 2010.
Family doctor or clinic: ________________________________________________
Phone: ________________________________________________
Insurance coverage: ________________________________________________
Policy number: _________________________ Subscriber ID: _______________________
Student's birthdate: ______________________________
DRUG ALLERGIES OR SPECIAL MEDICAL INFORMATION: __________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
I, the undersigned parent or guardian of ____________________________________, a minor, do hereby
authorize Robert Carr, as agent for the undersigned, to consent to any X-ray, examination, anaesthetic,
medical or surgical procedure or treatment and hospital care to be rendered to the foregoing minor in case
emergency medical treatment is needed, pursuant to the provisions of Section 25.8 of the California
Civil Code.
Signature of parent or guardian ______________________________________
Date _______________________