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Georgia 4-H at Camp Jekyll: Environmental Education

Parent/Guardian Permission Slip

This is only a SAMPLE.

Student Name ________________________________

Grade ____________

Teacher ________________________

School _________________________

For your child to participate in this educational field study, it is necessary for him/her to have your permission and for you to supply certain required information. Please complete the following form and return to school with check or cash by _____________________________.

  1. My child has permission to participate in the environmental education field study at Camp Jekyll.
    Yes ______ No _______
  2. My child has permission to participate in all classes chosen by school personnel.
    Yes ______ No _______
  3. I understand my child must have accidental insurance coverage to attend the trip to Camp Jekyll. Georgia 4-H is not responsible for medical coverage. The students must be covered by a parent/guardian or school policy.
    ______ My child is already covered by an insurance policy.

    Company Name: ___________________________
    Policy No.: _______________________________

    ______ I will need to purchase a school insurance policy (the school policy with _________________ costs $ ______).
  4. I give permission for my child to be taken to a doctor or hospital for medical treatment should the need arise.
    Yes ______ No _______
  5. The phone numbers where I can be reached in case of emergency are:
    Day #1 _____________________ Day #2_____________________
    Evening #1 __________________ Evening #2 __________________
    Alternate person if I can't be reached __________________________
    Relationship _________________ Phone # ___________________
  6. Special information (allergies, food restrictions, special services required):

Parent/Guardian Printed Name __________________________

Parent/Guardian Signature ________________________ Date ___________