PEORIA HIGH SCHOOL FINE ARTS

Peoria Ballet TRIP INFORMATION

Dear parent or guardian,

Your child is invited to attend a performance by Peoria Ballet at Five Points in Washington, IL
on Friday, April 7th, 2017. Please take a moment and fill out the necessary medical information
on the attached page. Also, please share the following information with your child before the
event:

What time will the transportation leave be at PHS? 9:30 AM

When will we return to PHS? 1:30 PM

Students will need money for lunch at McDonalds in Washigton

Dress nice for the performance.

Please turn in this slipand the medical form by Wednesday, April 5, 2017, to Mr. Webb.

I am aware that my child will travel by district transportation starting at Peoria High School
to the event listed above. A member of the district staff will be with your child for this event.
Please sign & date below and return by 4/5/2017

Parent signature:________________________________

Emergency cell phone:____________________________

MEDICAL PERMISSION RELEASE
(ALL INFORMATION BELOW WILL BE KEPT CONFIDENTIAL)

I,__________________________________________________ parent/guardian of
___________________________________________________(student)
give permission to PSD 150 Staff to secure and authorize emergency medical care or treatment
as may be necessary while under the supervision of said person on April 7th, 2017. I also
guarantee payment of all charges incurred during this medical treatment (physician, hospital, x-
ray, lab, drugs, ambulance, etc.). Further, I do not & will not hold PSD 150 Staff, Peoria High
School, or Peoria Public School District #150 responsible for any accidental injury or death
during the time frame listed above.

Date__________________
Parent/Guardian Signature_____________________________

Name of Family Physician______________________________________________

Office phone________________________________________________

Special Medical Problems__________________________________________

Allergies__________________________________________________

Medications_______________________________________________
Purpose_____________________

Date of last Tetanus Shot_____________________________________

Insurance_________________________________________________

Parent/Guardian Phone_____________________________________

Parent/Guardian Emergency Phone___________________________

***For emergency purposes please list the students cell phone number he/she may have with
them on the trip. This will be kept confidential.

Student Name-
Cell Phone-