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Name of student:
THE SCHOOL DISTRICT OF PHILADELPHIA
SchoolSchool PhoneGrade/RoomDate Prepared
Educational Purpose of Trip
Date of TripTrip Itinerary (summary)
Method of TransportationCost to Student
I understand that in case of any emergency requiring medical treatment, every effort will be made to reach
one of the people listed above. If none of these people can be contacted, I authorize the school to give
consent to treatment as deemed necessary by emergency responders.
Print Name of Parent/s or Guardian/s:
Signature of Parent/s or Guardian/s:Date:
Leave TimeReturn Time
A copy of this form is to be kept on file until the end of the school year.
I.D.#:Date of Birth:
Student lives with (check all that applies): Father Mother Guardian
If the parents/guardians cannot be reached, the school will call the people listed below. The people listed
below should be responsible individuals who can: 1) give permission to administer health care; 2) pick up your
child if your child is ill; 3) have the authority to speak on behalf of the parents or legal guardians.
If permission is granted, please provide the following medical information or if your child does not have any of
the health conditions listed below, please write “none”.
Medication/s being taken by student:
Allergies to foods, drinks, insect bites, medications, other:
Other medical information:
I have read the trip information to:
Please complete and detach the bottom part of this form and return to teacher
EH-80 Parental Permission (Rev. 10/06) - THE SCHOOL DISTRICT OF PHILADELPHIA
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