Georgia Studies Tour
Student Information Form

Student Information

Last Name:
First Name:

Middle Initial:

 

Address:

 
City:
State:

Zip Code:
 
Parent/Guardian Name:

 
Home Phone:  770-521-7622
 		Work Phone:  770-521-7622
Cell Phone: 770-521-7622
 
Student Date of Birth: (mm/dd/yyyy)
 
Sex:
 Height:  5'  5"
Weight:

 
Family Physician Name:
Phone: 770-521-7622
 

 

Please provide information concerning the following health related questions on the lines provided.

   
Allergies:
Chronic Illness:
Recent Illness:
 

Please provide information concerning any prescription medications that you take on a on a regular basis. Each medication will require a separate “Authorization to Give Medication at School” form.  This form and the medication itself must be turned into the clinic by August 29..  If the medication is a prescription, the student’s physician MUST sign the form.
 
Name of Medication Dosage Times to be taken
 
     
 

MEDICAL AUTHORIZATION And LIABILITY RELEASE

Should my child sustain or incur any accident or illness while on the Georgia Studies Tour, I hereby authorize the director, his agent, to execute any and all documents, including any necessary releases, which might be required by any medical facility to perform any emergency care on my behalf.  In the event that my child has an illness or accident during the program which requires a visit to the doctor or hospital, the existing family or school policies will solely represent the insurance coverage.

I give my permission for my child to participate in any and all activities on the Georgia Studies Tour and do not hold the Georgia Studies Tour or Fulton County Schools liable for my child.

  
To the best of my knowledge I certify that my child, , is in good physical condition, and that the information provided above is accurate.
 		  
I have read and agree to the information above: 
 		  
   

Is your child covered by a health or accident policy? 

**If no, insurance must be purchased through The Travel Store.

  
Name of Insurance Plan
  
Group Number
  
Name of Insured
  
Insured Person’s Social Security Number (111-22-3333)
  
Any other Insurance Identification Number
  
Any other pertinent information
  
   
Meal Options:  (If your child has dietary restrictions, please note below i.e. vegan, gluten free, etc.)  
 
   

Parent Permission Form For Instructional Use of Videotape - Fulton County Schools

 

  

Please indicate below if you DO/DO NOT give permission for your child to view the type of videotapes named on this form.  Parental permission is required for students to view videotapes rated Parental Strongly Cautioned (PG-13).  The videotapes will be shown for entertainment purposes while traveling on the bus during the Georgia Trip.

  
   

Rating: Parental Guidance (PG) 

 
   
   

After you have filled in all pertinent information above, press the Submit button below. 
When the confirmation page appears please print it out for your records.

After the confirmation page prints you will need to use your browser "back button" to return to the Information page.
Please remember to print and sign the Student Permission Form located on the Information page.