NORTH JAKARTA INTERNATIONAL SCHOOL

MEDICAL RELEASE FORM

I hereby grant the supervisors of the Grade 10 Field Trip to Carita

Ms. Jane MitchellMr. Andrew Beck

Power of guardian over my son/daughter, _____________________________ Student’s Full Name

From 27 April 2009 to 01 May 2009 while he/she is on the field trip.

In addition, the above named supervisors of the NJIS field trip have my permission to authorize any emergency medical treatment as recommended by a qualified physician and/or hospital, including emergency evacuation to a hospital in another country.*

__________________________ _________________________ ___________Print Parent’s/Guardian’s Name Parent’s/Guardian’s Signature Date

Home Address of Parent/Guardian:

______________________________________________________________________________

______________________________________________________________________________

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_______________________________ _______________________________ Home Phone Number Mother’s Handphone Number

_______________________________ _______________________________ E-Mail Address Father’s Handphone Number

*You will be contacted of any emergency arises.