Bentonville High School PERMISSION TO TRAVEL FORM

Trip Information:
School Contact(s): Contact Phone: Date of Travel: Location of Travel: Departure Time: Return Time: I/We give permission for __________ ______ _______ to travel on school provided transportation for this school-related activity. I/We understand that all students involved in this activity will travel to and from school on school provided transportation unless clearance has been made by the teacher, coach, principal or doctor due to extenuating circumstances. I/We acknowledge that the return time to school for these events is sometimes at a late hour (note Return Time above). A reliable means of transportation home for the student will be waiting when the student returns to the school.

Home/Family Information:
Home Address: Phone: Insurance Company: Parent Signature Emergency Phone: ID#: Date _____________ Student Signature Date

DECA STATE CAREER DEVELOPMENT CONFERENCE

PERMISSION SHEET

This is to state that my son/daughter named below has permission to attend the DECA State Career Development Conference, relieving the Vocational and Technical Education Division, local advisor and local school district of any responsibility which does not come under the term reasonable, and further agree that the state and chapter advisors shall have the authority to control and enforce the listed rules and regulations which have been deemed advisable and reasonable for all students attending this event. I understand that my son/daughter may be sent home for violations of any of the rules and regulations. Reasonable attempts will be made to contact local school authorities and parent (s) or guardian (s). Those contacted will be given an opportunity to determine the mode of transportation for my son/daughter and will be responsible for the expenses involved. ________________________________________________________________________ Name of Student

________________________________________________________________________ Name of School

________________________________________________________________________ Parent or Guardians Signature

________________________________________________________________________ Date

___________________________________ Home Phone Number

__________________________________ Business Phone Number

NOTE: A signed permission slip for each student attending must be submitted, along with the school agreement form, during conference registration.

AUTHORIZATION TO TREAT A MINOR

I (we) the undersigned parent, parents, or legal guardian of _____________________________________, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis of any member of the medical staff or emergency room staff licensed under applicable law of any hospital holding a current license to operate under applicable law. It is understood that this authorization is given to provide authority and power to render care which aforementioned physician in the exercise of his/her best judgment may deem advisable. It is further understood that an effort shall be made to contact the undersigned prior to rendering treatment to patient, but that in an emergency situation, necessary treatment will not be withheld if the undersigned cannot be reached.

List any restriction: ____________________________________________________________________ _____________________________________________________________________________________ This consent shall remain effective until ______________________________________________20____ Allergies to drugs or foods: ______________________________________________________________ Any special medications or pertinent information: ____________________________________________

Telephone numbers where parents (guardians) may be reached: Father Mother ____________________ ____________________ ____________________ ____________________ Home Business Home Business

Family Physician (name) _______________________________________________________________

Address _________________________________________________ Phone _______________________ Insurance Company _____________________________________ Policy No. ____________________

_____________________________________________________________________________________ (Signature of Father, Mother, or Legal Guardian) Date

_____________________________________________________________________________________ Address City State Zip

_____________________________________________________________________________________ ADVISOR SHOULD BRING WITH THEM TO CONFERENCE A COPY FOR EACH STUDENT