NORCAL ENVIRONMENTAL STUDENT NETWORK
Student Permission and Medical Authorization Form

Trip Destination and Title:

Primary Organization:

Trip Dates:

Nature of Trip:

I, the undersigned parent or guardian of _______________________ give my permission for him/her to go on the above named trip.  I further consent and allow the trip leader or such authorized substitute to consent to any X-Ray, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above named minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and/or surgeon licensed under the Provision of Medical Practice Act and/or dentist licensed the Dental Practice Act, wheather such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

Minor's Adress:


Minor's Birthdate and age:


Special medical or health problems:


Name of parent or guardian (print):


Parent or guardian signature and date:


Parent or guardian telephone numbers (home/work):

Family physician:


Address:


Insurer and account number: