CORE Placer Field Trip Consent & Emergency Form
You will only need to complete this form once. This form will be used for the entire 2017-18 School Year. Please submit 1 per student if you have more than 1 student attending CORE.
Email address *
*
Personalized Learning Teacher Name *
Student First Name *
Your answer
Student Last Name
Your answer
Student Grade Level *
Student Street Address *
Your answer
City/Zip *
Your answer
Student Date of Birth *
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Student Age *
Your answer
Parent/Guardian Name *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
I acknowledge that any program endorsed by the school is part of the educational process and provides a learning experience of educational value to my child. I hereby give my consent, accept all liability and hold CORE Placer Charter School harmless for the above student to participate in all school‐sponsored field trips or events in the 2017-18 school year. *
Date *
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Authorization & Consent for Medical Treatment: In case of an accident involving injury or suspected injury, or in the case of illness, I hereby authorize a member of the CORE Placer Charter School staff to transport my child to the nearest available emergency room and/or authorize treatment for my child. I hereby make, constitute, and appoint CORE Placer Charter School and its staff, full power to consent to any x‐ray, examination, and anesthetic, medical, or surgical diagnosis or treatment and hospital care to be rendered to my child on the advise of any physician or surgeon licensed to practice in the jurisdiction in which our child is located. This authority is delegated by use for the interval of any field trip or event sponsored by CORE Placer Charter School in which my child is participating. In signing this document, I attest to the fact that these are my wishes. *
Date *
MM
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DD
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YYYY
Family Medical Insurance *
Your answer
Policy Number *
Your answer
Allergies or Health Conditions *
Your answer
Current Medications *
Your answer
Photo Release *
*
A copy of your responses will be emailed to the address you provided.
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