form-permission: transport emergency info

Permission to Transport & Emergency Form

Name(s) of Students(Required)

I give permission for my child/charge (“child”) or children and/or myself to be transported in a motor vehicle driven by staff or volunteers of Student Advocacy Center. I understand that all applicable laws regarding riding in a motor vehicle and directions provided by the driver and/or other adult volunteers must be followed.

I have read and understand that:

I and/or my child/ren will be traveling in a motor vehicle driven by an SAC staff or volunteer and we are to wear our safety belts (or be buckled into a car seat); while traveling.
We are expected to respect each other, the vehicles we ride in, and the people we travel with during the trip;
We are to remain in our seats and not be disruptive to the driver of the vehicle.
Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and
We are not required to participate in SAC programming, but grant permission, despite the possible risks.
I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, we may risk personal injury or permanent loss.

I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

Emergency Contact #1

Emergency Contact 1 Name(Required)

Emergency Contact 1 Relationship(Required)

Emergency Contact 1 Address(Required)

Emergency Contact 1 Phone Number(Required)

Emergency Contact #2

Emergency Contact 2 Name(Required)

Emergency Contact 2 Relationship(Required)

Emergency Contact 2 Address(Required)

Emergency Contact 2 Phone Number(Required)

Medical Information

Any known allergies?(Required)

Any medications that SAC staff should know about (such EpiPen, insulin, inhaler)?(Required)

Insurance Information

We need your insurance information in case of an emergency.

Insurance Company(Required)

Subscriber Name(Required)

Insurance Company Address(Required)

Policy Number / Type / Group Number(Required)

Family Doctor Name / Phone(Required)

Parent/Guardian Signature

Parent/Guardian Name(Required)

Parent/Guardian Signature(Required)

Date(Required)