Student Name:_____________________________________________
    SSN____________________________ Birthdate_________________
    If your son/daughter has any particular health problems or allergies,
    please describe:
    Please list the following information pertaining to medical insurance:
    Name of Insurance Company__________________________________
    Policy Number_____________________________
    Policy Holder______________________________________________
    Names of family to contact in an emergency:
    __________________________   ______________   ______________
           Name                                         Home Phone           Work Phone
    __________________________   ______________   ______________
           Name                                         Home Phone           Work Phone
    Please include the name and phone numbers of persons to contact should
    you not be at either of the above numbers:
    ___________________________   ______________   _____________
    Name/Relationship to Student              Home Phone         Work Phone
    ___________________________   ______________   _____________
    Name/Relationship to Student              Home Phone         Work Phone
                                                TRAVEL RELEASE
                    I give my consent for this student to represent Monett High School on
    activity trips without holding Monett R-1 Schools or trip sponsors responsible
    in case of accident or injury.
                    I give permission for accompanying sponsors to provide or cause to be
    provided any emergency medical attention as deemed necessary. I understand
     that I will be notified in the event of any emergency situation as quickly as possible.
                    This permission and authorization is valid for the period of August 1,
    2008 through August 1, 2009
    ______________________________    _________________________
    Student’s Signature                                 Parent or Guardian Signature
        This page must be returned to the principal’s office.