Martin Educational Parent Medical Release Form
Please print and complete and return to you MET Representative or School Trip Coordinator.
As the parent/legal guardian of ______________________________, I request in my absence the named child or adult be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians,nurses, dentists, and staff, to perform any diagnostic procedures, treatment procedures, and operative procedures to the above named individual. I have not been given any guarantee as to the results of any treatment if performed on the above named individual.I understand any financial responsibilities not covered by MET but are the obligation of the participant. Pre-existing conditions and air travel are not covered under this policy.
Any representative of either __________________________ (School) or Martin Educational Tours is designated to act on my behalf until I have been contacted.
Date of Birth _____/_____/_____ for the above named individual.
Date of last Tetanus Booster _____/_____/_____ for the above named individual.
List known allergies and reactions of the above named individual, including any allergies to Medicine.____________________________________________________________________________________________
Note other special medical problems about the above named individual.
____________________________________________________________________________________________
List medications the above named individual will bring with them.
____________________________________________________________________________________________
Family Physician:_____________________________________ Phone:_________________________________
Names of Parents/Legal Guardians:________________________________________________________________
Address:_____________________________________________________________________________________
City/State/Zip:_________________________________________________________________________________
Phone: H__________________________ W__________________________ Cell__________________________
Person Responsible for Charges (if different from above):______________________________________________
Address:_____________________________________________________________________________________
City/State/Zip:_________________________________________________________________________________
Phone: H__________________________ W__________________________ Cell__________________________
Other Person to Notify if Parent/Guardian is Unavailable:______________________________________________
Phone: H__________________________ W__________________________ Cell__________________________
Insurance Company:___________________________________ Policy or Group Number:___________________
Signature of Parent/Legal Guardian:_______________________________________________________________
I,________________________________________ agree to comply with the rules and regulations of
Martin Educational Tours, teachers, and chaperones. I understand inappropriate action (such as bringing,
purchasing, or using drugs or alcohol) during the trip will result in immediate dismissal from the trip.
Student Signature:______________________________________________ Date:___________________
In the event of student misconduct, I understand the following will occur:
1. The chaperone and my child will phone home to discuss the situation.
2. If not resolved by phone, my child will be sent home at my expense.
Signature of Parent/Legal Guardian:________________________________ Date:__________________