UGA Cooperative Extension: Georgia 4-H

Jekyll Island 4-H Center:
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 Jekyll Island 4-H Center.
   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 Jekyll 4-H. The Jekyll Island 4-H Center 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 ___________