Download - Class Trip 3 Medical Release Form
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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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________ _______________________________ Home Phone Number Mother’s Handphone Number
_______________________________ _______________________________ E-Mail Address Father’s Handphone Number
*You will be contacted of any emergency arises.