Take Stock in Children of Broward County

Health DayParticipant Authorization Form

Field Trip Date(s):Friday, March 18, 2016

Destination(s):Broward Health Medical Hospital

TSIC Scholar Information

TSIC Scholar Name: ______, ______

LastFirst M.I.

TSIC Scholar Cell Phone #: (______) - ______- ______

Emergency Contact Information

In case of emergency relating to the aforementioned TSIC Scholar, please contact:

Name: ______Relationship: ______

FirstLast

Phone: (______) - ______- ______

In the event that the above contact cannot be reached, please contact:

Name: ______Relationship: ______

FirstLast

Phone: (______) - ______- ______

Health/Accident Insurance

Please Check One:

  1. _____ My child is covered by 24 Hour accident insurance or family insurance:

Insurance Company: ______

Policy Number (or attach copy of card): ______

  1. _____ I do not have insurance, however, I will pay any and all medical bills for emergency and/or health care of my child, and agree not to hold Take Stock in Children or any of its affiliates responsible for costs incurred through such treatment.

*Please Sign Parent/Guardian Agreement on Back*

Parent/Guardian Agreement

I, the authorized parent/guardian of the aforementioned TSIC Scholar agree to allow my child to participate in the Take Stock in Children of Broward County Health Day Trip and agree to all policies and procedures associated with this event.

I understand that emergency treatment and care will only be taken when deemed necessary. I affirm that the emergency contact information provided is accurate and the contacts are knowledgeable and authorized to make decisions regarding an emergency incident involving this TSIC Scholar.

I acknowledge that I have received detailed information regarding this event and I understand these details are provided to me, for my benefit, but are liable to change without notice in the event of an emergency or other unpredictable factor. In the event of a change in plans, efforts will be made to contact the emergency contacts for the TSIC Scholar.

______

Parent/Guardian Name

______

Parent/Guardian Signature

_____ /_____ /______

Date