ECB Summer School Field Trip Waiver Form
Please complete this form to provide consent for participation in the upcoming field trip.
Participant Information
Student Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Please Select
Parent
Spouse
Friend
Other
Medical Details
Does the participant have any allergies, illness, or other diseases?
*
Yes
No
If so, please list them:
List any prescribed medication, if applicable:
Date
*
-
Month
-
Day
Year
Date
Participant/Parent/Guardian Signature
*
Submit
Submit
Should be Empty: