Visions for Success

Historical Black College Tour

Please print out this form and mail it to the address below.

I hereby give my consent for to receive emergency medical or dental care if deemed necessary by the physician or dentist while in attendance at Visions for Succcess (Black College Tour).

I agree to be financially responsible for any services rendered with respect to the emergency conditions.

Please select applicable Medical Concerns:

Allergies Asthma Attention Deficit Disorder Bi-polar

Diabetes Hypertension Pregnant Other:

LIST ALL MEDICATIONS THAT YOU MUST TAKE DURING THE TOUR:

For liability reasons, NO pregnant student is allowed to go on these tours. Failure to submit accurate medical information will be grounds for student dismissal from the tour.

FAMILY DOCTOR:
PHONE#:
NAME OF INSURANCE:
TYPE/GROUP:
POLICY#:

PERSON TO CONTACT IN CASE OF EMERGENCY:

NAME:
RELATIONSHIP:
DAY PHONE#:
NIGHT PHONE#:

I understand the chaperone in charge reserves the right to inform parent/guardian of the student's inappropriate behavior while on tour which may result in student being dismissed from the tour and sent home at parent/guardian's expense.

Signature of parent/guardian:
Date: