UPPER MORELAND MIDDLE SCHOOL
Below please find the necessary forms for your child's particpation on our Canada trip.
Please print a copy and complete the form and return to Mr. Grande.
Canada Permission Form
Medical Emergency Information
Medical Information Form
Back to Canada page

As the parent/guardian of _________________________________, I give my permission for my child to participate in the Upper Moreland Middle School-sponsored trip to Montreal and Quebec City.  I have read the information concerning the trip and understand the related details concerning payment, insurance, and student behavior.  I further understand that I cannot hold the tour organizers, the persons who provide transportation and related services, the school, nor the chaperons liable for injury to my child should my child not behave in a manner consistent with the expectations and guidelines outlined for this trip.

_____________________________________             ______________________
Parent/Guardian Signature                                                  Date

_____________________________________             (W)___________________
Home Address                                                                  Telephone
_____________________________________             (H)____________________
City, State, Zip                                                                  Telephone

e-mail address__________________________           

* Attached to this permission slip should be a completed medical release form and a check payable to the “Upper Moreland School District”.  The check should be made out for a minimum of $295.00.  Medical insurance & Cancellation insurance would be an additional $70.00. Medical insurance alone would be $ 12.00.

******************************************************************************
In the event of a medical emergency, hospitals in Canada charge a minimum admittance fee.  While this fee is refundable by your family insurance policy, it must be paid on the spot.  The fee is approximately $500.00.  Therefore, please fill in the line below with the name and number of a credit card we may use in case of a medical emergency.

___________________________________________________
Name on Credit Card

_____________________________________________________________________
Name and Number of Credit Card                                                              Expiration Date

              Medical Emergency Information    top
   READ AND COMPLETE CAREFULLY

In the event of a medical emergency, treatment will NOT begin until parental permission is obtained.

If your child is injured, the chaperon will attempt to reach you immediately. If you are unavailable/not reached, the medical release form below will enable treatment to begin while the chaperon continues to try to reach you.

________________________________                        ____________________________
Student’s Full Name                                                         Date of Birth

________________________________                        ____________________________
Parent/Guardian #1                                                          Parent / Guardian #2

Insurance Carrier (Name) ______________________________________

Policy # ________________________________

24-hr. Phone Number___________________

Student’s Physician ________________________________________

Phone # ______________________________

On the day of the trip and during the times of the trip, I/we will be at (phone number)

 __________________________________________________________________

On the day of the trip, the following person(s) will know how to reach me.

Name________________________________  Phone Number _________________

Name________________________________  Phone Number _________________

Confidential Medical Information   top

1. Describe below any medical problem that the chaperon/medical personnel should know.

2.  Is medication required?  (Describe completely--dosage and times needed)

3. Is your child allergic to any medication? (If yes, please describe.)

_____________________________________________________________________

MEDICAL RELEASE:
Should the need arise during the course of this trip, I hereby give my permission to the chaperons to have my son/daughter medically treated.  I also understand that the chaperons cannot be held responsible for the treatment administered by the doctor and/or nurse.
:____________________________                                                                                             
Home Phone                                                                                                                                                                                _________________________________________
Signature of Parent or Guardian

Emergency Phone: _________________________