Note:  No student will be permitted to travel with the group until we have this information.  Thank you for your prompt attention.

Student Name ______________________________________________________

Student's SS# ______________________________________________________

Parent's Name ______________________________________________________

Parent's Address ____________________________________________________

Parent's Phone (Home) _______________________________________________

(Work) ____________________________________________________________

Emergency Name ____________________________________________________

Emergency Phone ____________________________________________________

I give my permission for the above named student to receive medical treatment for all illness and/or injuries in my absence.

Parent/Guardian Signature ____________________________________________

Date ______________________________________________________________

Insurance Company __________________________________________________

Insurance Policy Number ______________________________________________

Student's Allergies ___________________________________________________

Student's Medications ________________________________________________

Date of last Tetanus Shot ______/______/______

Our chaperones have the following medications available.  Please circle those medicines NOT to be administered to your child:

Do you give your permission for us to administer these medications to your child?

Yes _____ No _____

Consent Acknowledgement and Release

Student Name _____________________________________________________

School Function/Trips:  Away Band Camp, All Away Football Games and Competitions, All Trips, All Concerts and All Festivals for the 2002-2003 School Year.

We, the undersigned parties of _________________________________ hereby consent
to our child's participation in the school trip(s) described above.

We further acknowledge and agree to the following:

The Fayette County Board of Education, its members, employees and agents assume no responsibility for personal injuries and/or property damage which might be suffered by our child, his property, or the person or property of others during said function/trip, and we hereby expressly release said Board of Education, its members, employees and agents from any and all liability relating to any such injuries or damages.

The Fayette County Board of Education's policies on Student Conduct and Discipline shall be in full force and effect as to all student participants in this function/trip at all times during the same, and any violation of any rule(s) contained therein by our child may result in appropriate disciplinary measures including suspension and expulsion as provided in said policies.

The Fayette County Board of Education, its members, employees and agents are not responsible for any expenses related to this school function/trip except as otherwise specifically agreed by them in writing:

The Fayette County Board of Education may require as a condition to our child's participation in this school function/trip that satisfactory evidence be submitted indicating that our child has sufficient medical insurance in effect during the period of said function/trip.

This ________ day of _________________, 2003

Parent_______________________________

Student______________________________