2018-19 Grandview High School Theatre Medical and Field Trips Forms
All students attending the Colorado State Thespian Conference in December and/or the International Thespian Festival in June must fill out one of these forms.
Student Last Name *
Your answer
Student First Name *
Your answer
Choose your class *
Parent 1 email address *
Your answer
Parent 2 email address
Your answer
Medical Form: I/we give permission for this student to travel with the GHS Theatre Department during the 2018-2019 school year. I/we do hereby authorize officials of the Cherry Creek School District to contact directly the people named below and do authorize the named physician or associates to render such treatment as deemed necessary in an emergency, for the health of said child. In the event that parents, guardians, or other people named, or the physician on this form cannot be reached, the school officials are hereby authorized to take whatever action is deemed necessary in their judgement for the health of the aforesaid child. I/we understand that the district does not provide health or medical insurance on students. I/we further understand that I/we are responsible for payment of all health, medical and emergency care treatment provided for my child (ren) while participating on this trip. I/we grant permission for my son/daughter to use the following transportation: school bus, commercial bus lines, commercial airlines, adult driven automobiles, including sponsors and or parent drivers. I/we understand, and my son/daughter agrees that my son/daughter is to adhere to all Cherry Creek School District disciplinary policies and procedures while on this trip. I/we grant permission to the sponsors to do what is recommended and necessary to control or modify any behavior by my son/daughter who they (sponsors) perceive as being a violation of these policies, procedures, or that becomes a problem in any way, I/we will accept a collect call from the sponsors and with them consider the manner in which the problem will be promptly solved. *
Home Phone Number *
Your answer
Parent 1 Cell Number *
Your answer
Parent 2 Cell Number
Your answer
Alternate Emergency Number *
Your answer
Mother Work Number *
Your answer
Father Work Number *
Your answer
Doctor's Phone Number *
Your answer
Hospital Name *
Your answer
Name of Insurance Company *
Your answer
Address of Insurance Company *
Your answer
Insurance Subscriber's Name *
Your answer
Student's Policy ID Number *
Your answer
Nearest Relative *
Your answer
Nearest Relative Phone Number *
Your answer
Date of Birth Insured *
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I/we hereby represent to the Cherry Creek School District that the student is in good physical health and the trip does not pose a health hazard to the student. *
I/we hereby grant permission and give consent for the above named student to 1) be treated by any qualified nurse, physician or surgeon as may be deemed necessary by CCSD, its agents, servants or employees during the trip: 2) be administered medication and or emergency first aid care as may be necessary or appropriate; 3) receive treatment in hospitals, medical offices, clinics, or elsewhere in the event of accident or illness. I/we understand and agree that neither CCSD nor its agents, servants, or employees are responsible for obtaining or for the result of any medical or emergency treatment rendered or supplied to the student. I/we will hold the CCSD, its agents, employees, and servants harmless and indemnify them from any claim, cause of action or demand arising out of any form of (or lack of) medical or emergency treatment rendered to the student. *
Please list all allergies, medications, or other medical problems which your son/daughter has *
Your answer
The student fully agrees and consents to the foregoing *
Required
Date of Student Agreement *
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Parents/Guardians fully agree to the foregoing *
Date of Parent Agreement *
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Address of Student *
Your answer
Address of Parent/Guardian if different
Your answer
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