| NICE Community
Schools
Ishpeming, MI 49849
I
hereby give permission for BPA Advisors Carol Cox, Ronalyn Arseneau,
or Debra DeVries of Westwood High School to authorize emergency medical
treatment for my son/daughter while on a school sanctioned trip with
the Westwood Business Club.
| Student: |
| Address: |
| Locker
Number: |
Year
of Graduation: |
| Date
of Birth: |
Cell
Phone: |
| |
| Parent/Guardian |
| Name: |
| Address: |
| Home
Phone: |
Work
Phone: |
Cell
Phone: |
| Parent/Guardian
Employer: |
| |
| Important Medical Information |
| Physical
Disabilities: |
| Allergies: |
| Medication
(s) used presently: |
| Family
Physician: |
| Physician
Address: |
| Physician
Home Phone: |
Physician
Business Phone: |
Medical
Insurance Carrier(s):
|
Certificate
No.(s) :
|
___________________________________
Parent/Guardian Signature
| Legal
Notarization
Subscribed and sworn before me on_____________________________
20____
Notary Public_________________________My Commission Expires__________
|
|