PCS - Chaperone Field Trip Excursion Notice and Medical Authorization

PACIFIC COLLEGIATE SCHOOL
VOLUNTARY FIELD TRIP /EXCURSION NOTICE
AND MEDICAL AUTHORIZATION – ADULT CHAPERONE

Dear Chaperone,

Please complete this form and return to the School office.
Destination:
Departure Date & Time:

MonthDayYear
Date
Hour MinutesAM/PM Option
Return Date & Time:

MonthDayYear
Date
Hour MinutesAM/PM Option
Printed Name:

First NameLast Name
Email*
example@example.com
Signature

Clear
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Medical Insurance Carrier:
Medical Insurance Carrier Policy Number:
Medical Insurance Carrier Phone Number:
Please enter a valid phone number.
In the event of illness or accident, please notify:
Name

First NameLast Name
Day Phone
Please enter a valid phone number.
Evening Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have any special medical problems, attach a description of the problem to thissheet, or list here:
Should be Empty:

In the event of illness or accident, please notify: