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Student Field Trip Permission Form University Liggett School Student School Year last first Home Phone Birthdate Parent/Guardian- Work Phone Mobile Phone email Grade ADDITIONAL MEDICAL INFORMATION Family Physician Phone Health Insurance Company and Policy Numbers J I hereby authorize ULS to administer an age-appropriate dosage of Tylenol to my child if deemed necessary. FIELD TRIP INFORMATION has my permission to participate in the school-sponsored trip to first name last name on In the event of emergency if neither parent nor physician can be contacted or if there is not time to make such contact the following signature authorizes such medical and surgical treatment as may be deemed necessary. Parent s Signature Date J Full lunch provided J Bring food only no beverage J Bring full lunch J Bring beverage only non-glass container J Free dress J Wear uniform/school dress J Other. FIELD TRIP INFORMATION has my permission to participate in the school-sponsored trip to first name last name on In the event of emergency if neither parent nor physician can be contacted or if there is not time to make such contact the following signature authorizes such medical and surgical treatment as may be deemed necessary. Parent s Signature Date J Full lunch provided J Bring food only no beverage J Bring full lunch J Bring beverage only non-glass container J Free dress J Wear uniform/school dress J Other.

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