COLLEGE BOUND TRIO PROGRAM FIELD TRIP PERMISSION SLIP Students Full Name _________________________________ home phone ______________

Address ____________________________________________ cell phone ______________ I/we the parents/legal guardian of the above named student at Stadium High School, hereby give my/our permission to participate in the Snow Tubing trip in Snoqualmie Pass, WA, on February 15, 2013, sponsored by the Metropolitan Development Councils College Bound (College Bound). I/we freely and voluntarily assume any and all risks of injury and damage which might result from the students participation in educational, cultural and recreational field trips as scheduled by College Bound personnel. I/we understand that said activities may expose the student to risk of bodily injury, death, or damage to the students property. I/we hereby release and forever discharge Metropolitan Development Council, its employees, officers or agents from all liabilities, actions, claims, costs and expenses arising out of my students participating in the College Bound Program, which includes but is not limited to, the transportation of the student, classroom activities, field trips and special events. I/we attest that I/we will pay his/her medical expenses in the event of an accident or illness. I/we understand that by law, hospitals cannot treat minors without parental authorization, except for a life or death situation. Therefore, in the event that my child needs emergency medical care, and I/we cannot be contacted, I/we authorize treatment as necessary, whenever injury or illness is sustained. **If possible please have both parents sign. Students Signature__________________________________ Date_________________ Fathers/Guardian Signature___________________________ Date_________________ Mothers/Guardian Signature__________________________ Date_________________ EMERGENCY INFORMATION Parent Home Number:_____________________ Parent Cell Number:____________________ Alternative contact in case of an emergency:______________________________ Emergency Contact Phone Number:_________________________ Medical Insurance Carrier:_____________________________________ Policy Number:________________________________________ Physicians Name:______________________________________ Physicians Phone Number:______________________________ Hospital Preference:__________________________________________ List any medical conditions we should be aware of (ex. Allergies, diabetes etc.)