TOWNSHIP HIGH SCHOOL DISTRICT 214

The undersigned certified that he/she is the parent/legal guardian of

Student Name

that the student will be traveling to various locations as a participant in an educational tour/field trip sponsored by said District 214; that Sara Michael/Connor See/ Ariana Cappuccitti/Joann Langley/Jonathan Boyer who is an employee of Township High School District 214, whose address is 2121 South Goebbert, Arlington Heights, IL, is in charge of the students during such educational tour/field trip; and that the educational tour/field trip will last from July 1, 2022 to June 30, 2023. If the parent(s) or guardian(s) cannot be immediately contacted, the undersigned does hereby grant full power of attorney to Sara Michael/Connor See/Ariana Cappuccitti/Joann Langley/Jonathan Boyer, in the event of accident or illness to his/her child from the commencement to the termination of the tour/field trip to do as follows:

1. To arrange for the transportation of

Student Name

whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, the emergency room of a hospital, a doctor’s office.

2. To sign such releases as may be required in order to obtain such immediate medical or surgical treatment as is required in the judgement of the medical authorities at said facility.

Signature of Parent/Guardian

Clear

Date

NAME OF PARENT/GUARDIAN

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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