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2017 Southeastern Orlando Field Trip Contract Marching Panthers & High School Choir SOUTHEASTERN MARCHING BAND & HS CHOIR JEFF DONAHUE & CAROLYN MILBAUGH, DIRECTORS DESTINATION: ORLANDO, FLORIDA DATES: MAY 30-JUNE 4, 2017 Trip Leaders Mr. Jeff Donahue - Marching Panthers - 740-774-2003 ext. 3424 [email protected] Ms. Carolyn Milbaugh - High School Choirs - 740-774-2003 ext. 2152 [email protected] Trip Company Bob Rogers Travel 3440 Lacrosse Lane, Naperville, IL 60564 1-800-373-1423-Phone http://bobrogerstravel.com/ Trip Timeline and Cost Please note all monies deposited are non-refundable from the school. Please see trip insurance plans attached. Date Description Monev Due May 16 Trip Contract & Trip Payment 1 $50.00 September 1 Trip Payment 2 $170.00 November 1 Trip Payment 3 $170.00 January 3 Trip Payment 4 $170.00 February 1 Trip Payment 5 $170.00 March 1 Trip payment 6 $170.00 plus any additional costs. Final payment based on total number of trip participants and room selection Tour Costs, Inclusions, and Itinerary - Attached Summary of papers to turn in on May 16: • Trip Payment #1 Form - $50.00/person • Eligibility/Disciplinary Action Agreement - Attached • Adult Chaperone Information - Attached • Sibling Information Form - Attached • Student/Adult Permission & Medical Release Form - Attached
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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

SOUTHEASTERN MARCHING BAND & HS CHOIRJEFF DONAHUE & CAROLYN MILBAUGH, DIRECTORS

DESTINATION: ORLANDO, FLORIDADATES: MAY 30-JUNE 4, 2017

Trip LeadersMr. Jeff Donahue - Marching Panthers - 740-774-2003 ext. 3424

[email protected]. Carolyn Milbaugh - High School Choirs - 740-774-2003 ext. 2152

[email protected]

Trip CompanyBob Rogers Travel3440 Lacrosse Lane, Naperville, IL 605641-800-373-1423-Phonehttp://bobrogerstravel.com/

Trip Timeline and CostPlease note all monies deposited are non-refundable from the school.Please see trip insurance plans attached.Date Description Monev DueMay 16 Trip Contract & Trip Payment 1 $50.00September 1 Trip Payment 2 $170.00November 1 Trip Payment 3 $170.00January 3 Trip Payment 4 $170.00February 1 Trip Payment 5 $170.00March 1 Trip payment 6 $170.00 plus any additional

costs. Final payment based on totalnumber of trip participants and roomselection

Tour Costs, Inclusions, and Itinerary - Attached

Summary of papers to turn in on May 16:• Trip Payment #1 Form - $50.00/person• Eligibility/Disciplinary Action Agreement - Attached• Adult Chaperone Information - Attached• Sibling Information Form - Attached• Student/Adult Permission & Medical Release Form - Attached

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

Luggage Allowed on TripInstrument Case/Flag Under BusUniform Garment Bag/Shoes/Gloves/Hat/Hat Box/Plume1 Large Suitcase Under Bus1 Medium Small Overhead Compartment sized bag/luggage1 Small Bag or Small Cooler for under seat.Headphones for portable devices you choose to bring.

Items Not Allowed on TripGuitars or other hand held musical instruments.Portable loudspeakers for devices.Large Gaming Consoles such as Xbox or PlayStation that require a tv/monitor to be used.Inappropriate music/movies/games whether using headphones or not. Keep it rated G,

PG, and E for everyone. Remember that we are on a school trip and traveling to Disney whereour code of conduct is looked at closely.

No alcohol, tobacco products, drugs. Any medications needed must be listed on youremergency medical form and held by the trip leader. Anything you consider so valuable that youcould not live without such as a sentimental article of clothing, jewelry, electronic device, photo,etc. If it is so valuable do not bring it because the school will not be responsible for lost, stolen,misplaced, or forgotten items. There will not be time to go back to look for items you aremissing. Do not bring anything you consider so valuable if you lose it your trip will be ruined.Only bring items you could live without if lost, stolen, misplaced, or forgotten.

Hotel RoomsStudent participants will be housed in hotel rooms with 4 to a room with other student

participants. Boys and Girls will sign up for quad occupancy on separate sheets. Studentparticipants are required to fill as many rooms as possible with 4 to a room. If there is an oddnumber after the quad occupancy has been filled, there will be overflow into triple or doublerooms at no additional cost to student participants. Student participants may pay extra for aguaranteed triple, double, or single room, but this is optional. Each student in the optional tripleor double room must each pay the additional amount or the room request will be cancelled.Chaperones and other trip members will be housed in quad rooms at the same trip rate as studentparticipants. Chaperones who wish to be housed in triple, double, or single rooms may requestone for an additional cost. The additional cost for optional room upgrades will be due on the finaltrip payment.

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

Chaperone InformationChaperones will be needed on the trip. Parents are encouraged to travel with the school

group as part of the trip. Other individuals who may wish to participate will be considered afterall parents have signed up and if there is still room on the bus. Preference will be given toStudent participants and Parent chaperones first. We are planning to take 3 charter buses eachwith 165 seats available. Chaperones must be 21 years of age and approved by the Board ofEducation. Chaperones who participate on the trip are expected to ride the bus and activelyparticipate with the itinerary and will be expected to chaperone small groups of students eachday during the trip. Chaperones help ensure the safety of our student participants by helping tokeep track of where each student is at all times and notifying the trip leader of any medical orbehavior problems when they occur. Chaperones are to serve as positive role models for thestudent participants and to refrain from inappropriate language, alcohol, and tobacco use whileon the trip. In order to be a chaperone on the trip, you must travel with the school group on thecharter buses and remain with the school group for the duration of the trip. If a parent wishes atthe conclusion of the trip to sign their student out and remain in Florida, they may seek priorapproval through the school administration. Likewise, students must travel with the school groupon the charter bus to Florida and remain with the school group for the duration of the trip inorder to be considered a participant. Parents/Adults who wish to travel on their own to Floridawill not be considered chaperones on this trip. Parents/Adults who wish to remain in Florida atthe conclusion of the trip will forfeit their return seat on the charter bus and will not receive a tripdiscount or refund because they did not return with the school group on the charter bus. Anyparent chaperone wishing to sign their child out at the conclusion of the trip must receive priorapproval from the high school principal and trip leaders. Parents/Adults who desire to meet theschool group at the conclusion of the trip and sign their child out must understand that there willbe a small window of opportunity during the trip to meet and sign their child out. If the parent islate or does not know where to go, the student participant will be required to board the charterbus and return with the school group at the conclusion of the trip. No student will be leftunattended during the trip and the trip itinerary will not be altered to accommodate waiting forsomeone to be picked up.

Marching Panther PerformanceThe Southeastern Marching Panthers will be performing in a Disney Magic Music Day's

parade performance at Magic Kingdom during the trip. The parade is the pre-electric light paradein the evening. Students will march in full uniform for the performance.

High School Choir PerformanceThe Southeastern High School Choir will be singing at a Disney Performing Arts On

stage performance at a location to be determined.

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Mafctogi Moments TtatMatitrSOUTHEASTERN HS BAND a CHOIR

JEFF DONAHUE & CAROLYN MILBAUGH, DIRECTORSDESTINATION: ORLANDO, FLORIDA

DATES: MAY 30-JUNE 4, 2017

TOUR COSTS a INCLUSIONSAS OF

AAAY4, 2016Mike Crandall, Account Manager

Jenny Fackler, Travel Coordinator

SUMMARY OF INCLUSIONS

• Personal SERVICE and ATTENTION• Three (3) Deluxe 56 passenger, climate controlled, DVD a Wi-fi and restroom

equipped motor coaches• Gratuities and accommodations for your motor coach drivers• Two (2) night's accommodation at Fairfield Inn a Suites Savannah -1-95 South (or

s i m i l a r ) ~• Three (3) night's accommodation at Buena Vista Suites (or similar)• One (1) Private nighttime security guard at the Orlando hotel (10:30 PM-5:30 AM)• Five (5) Breakfasts at the hotel• Group dinner at Planet Hollywood• Two (2) Disney Dining cards ($15 each)• 3-Day Premium ticket to the Walt Disney World® Resort• Disney 'Performing Arts on Stage' Performance (based on availability and

acceptance)• Bob Rogers Travel Drawstring Bag for each participant• All taxes, service charges, and gratuities for restaurant and hotel facilities• Bob Rogers Travel Tour Manual

Bob Rogers Travel Hotel Contract- Assurance that the hotel will abide by thestudent friendly bylaws that BRT has agreed upon with the hotel.

' Insurance Coverage as Recommended by Student Youth Travel Association• $200,000 Consumer Protection Plan• Company Tour Director - On-site trip coordinator--manages all trip details at

destination

• S Y T A f f i f M

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^h^Metslfm'eiNON-INCLUSIONS / OPTIONS

• Meals stated as student cost• Group Travel Video Souvenir Package - A great keepsake of a fabulous trip!

Digital cameras will be sent. Take pictures throughout your tripy then mailback the cameras AND a recording of your music. A souvenir video will becreated, and each traveler will receive a DVD copy.• Bob Rogers Travel Individual Payment System

ESTIAAATED TOUR PACKAGE COSTS (based on 150-154 paving participants)*Based on three motor coaches.

$915.00/person (based on quad occupancy)$1,015.00/person (based on triple occupancy)$1,109.00/person (based on double occupancy)$1,499.00/person (based on single occupancy)

ESTIMATED TOUR PACKAGE COSTS (based on 155-159 paving participants)*Based on three motor coaches.

$905.00/person (based on quad occupancy)$1005.00/person (based on triple occupancy)$1,099.00/person (based on double occupancy)$1,489.00/person (based on single occupancy)

ESTIAAATED TOUR PACKAGE COSTS (based on 160-164 paving participants)*Based on three motor coaches.

$895.00/person (based on quad occupancy)$995.00/person (based on triple occupancy)$1,089.00/person (based on double occupancy)$1,479.00/person (based on single occupancy)

ESTIMATED TOUR PACKAGE COSTS (based on 165-167 paving participants)*Based on three motor coaches.

$885.00/person (based on quad occupancy)$985.00/person (based on triple occupancy)$1,079.00/person (based on double occupancy)$1,469.00/person (based on single occupancy)

'SYTA, WMWM

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BrTfabl&de/fTFffletMaMnrtj Moments That Matter

ASSOCIATIONS

• OMEA Level III Corporate Partner 2i|#l rP ..! . ■ 'TVPresident's Club

Ohio Choral Directors Association (OCDA)Student a Youth Travel Association (SYTA)National Tour Association (NTA)International Air Transport Association (IATA)Bandmasters' Associations - Iowa, Missouri, TexasMidwest Band and Orchestra ClinicMembers of 12 State Music Associat ions U A rr &A)B1A#TCIJO f fi c i a l S p o n s o r o f M a k e - A - W i s h M A J \ t ' ^ j j Y l b f t ,

ACCOLADES• 2011 -'15 Top Overall Producer Award - Disney Performing Arts

Disney's Partners Award• Disney Youth Travel Planner Symposium (Since 1993)• Thanksgiving Parade of Bands• Disney Top 5 Student Travel Planner

C"r>.i'Ho «fr* J'

Walt Disney World® ResortPARTNERS AWARD

Presented toBob

For exemplqny0$within 'ttfeM

providing quality ex|er/e.^|business integrity

pmmotinsrthg

FINANCIAL PROTECTION a INSURANCE• When you travel with BRT your investment is protected• Professional liability insurance• Optional Trip Cancellation Insurance• Covered by SYTA Consumer Protection Plan for $200,000

O ' S Y TA

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

SUGGESTED ITINERARY AS OF APRIL 25. 2016Mike Crandall, Account ManagerJenny Fackler, Travel Consultant

TUESDAY, MAY 307:00 AM The motor coaches arrive at Southeastern High School for loading.

2003 Lancaster Road, Chillicothe, Ohio 456018:00 AM Depart via deluxe air conditioned motor coaches with DVD. (10 54 hours have

been allotted for drive plus 3 hours for breaks, lunch and dinner on your own, anda driver change.)

9:30 PM Arrive in Savanna, Georgia at your hotel for the evening.Fairfield Inn & Suites Savannah -1-95 South (or similar)

**A Bob Rogers Travel Representative will meet you here to assist with check-in. **

WEDNESDAY, MAY 317:00 AM Breakfast included at the hotel.8:00 AM Board coaches for Orlando (5 hours have been allotted for drive time, plus 1 hour

for lunch on your own and breaks).2:00 PM Arrive in Orlando at Blizzard Beach where the Florida sun meets alpine snow in

the coolest Water Park around. Legend has it that a freak snowstorm resulted inFlorida's first ski resort, but when temperatures rose, the Florida sun turned the skiruns into water slides. Now, the thrills peak high atop some of the highest slideson earth. Experience Summit Plummet, a breathtaking 60-mph plunge straightdown, or the Downhill Double Dipper, the world's only side-by-side racing slidesor Melt-Away Bay a one-acre bobbing wave pool, constantly fed by "meltingsnow" waterfalls.

1534 Blizzard Beach Drive**Your professional Tour Director will greet you here. **

6:00 PM Transfer to the Disney Springs area, a themed retail, dining and entertainmentcenter inspired by Florida's charming waterfront towns, historic architecture andnatural beauty. With over 150 different stores, restaurants and entertainmentvenues enjoy a relaxing evening Disney style!1780 East Buena Vista Drive

7:00 PM - Have dinner at Planet Hollywood at Disney Springs. The largest in the world, thethree levels are densely decorated with movie memorabilia and props from someof Hollywood's hottest films and TV shows.506 East Buena Vista Drive

10:00 PM Transfer to your hotel to check in for the evening.Buena Vista Suites (or similar)

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

Private Security Guard on duty - 10:30 PM-5:30 AMTHURSDAY, JUNE 17:30 AM Breakfast at the hotel.9:00 AM Spend the day experiencing the Magic Kingdom! Capture the enchantment of

fairy tales with exciting entertainment, classic attractions, backstage tours andbeloved Disney Characters with seven whimsical lands. Be sure to hit suchattractions as Mickey's PhilharMagic, Pirates of the Caribbean, Space Mountain,the Haunted Mansion, and the classic It's a Small World.1180 Seven Seas DriveYou will have $15 on a Disney Dining Card to use towards dinner in the park.

8:30 PM The Southeastern HS Marching Band marches in this evening's Main StreetElectrical Pre-Parade! (Pending scheduling by Disney Performing Arts on Stage.)

10:00 PM Enjoy the Wishes Nighttime Spectacular, an incredible fireworks display and thebiggest, brightest fireworks extravaganza in Magic Kingdom theme park history.

11:00 PM Return to your hotel for the evening.Private Security Guard on duty- 10:30 PM-5:30 AM

FRIDAY, JUNE 28:00 AM Breakfast at the hotel.9:00 AM Transfer to Epcot Center for a day of fun. Divided into two areas, Future World

and the World Showcase. Future World focuses on technological advancements,innovation and wonder, and features attractions such as Soarin', Mission: Space,and Test Track. The World Showcase is a collection of pavilions that wraparound the Lagoon. Inside find shops, attractions and restaurants that represent theculture and cuisine of 11 countries.1510 North Avenue Of The Stars

3:00 PM Transfer to Disney's Hollywood Studios for the rest of the day! Enjoybehind-the-scenes glimpses of Hollywood-style action with live shows, thrillingattractions, and backstage tours. Highlights include the Twilight Zone Tower ofTerror, Rock 'n' Roller Coaster Starring Aerosmith, and the Indiana Jones EpicStunt Spectacular.351 South Studio DriveYou will have $15 on a Disney Dining Card to use towards dinner in the park.

8:30 PM Experience Fantasmic a spectacular, 25-minute fireworks and water show starringMickey Mouse and a bevy of delightful Disney Characters and featuring classicDisney music and songs, laser lights and amazing hydrotechnic effects.

9:30 PM Return to your hotel for the evening.Private Security Guard on duty - 10:30 PM-5:30 AM

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

SATURDAY, JUNE 38:30 AM Breakfast at the hotel. Check out of the hotel and board the motor coaches.9:00 AM Depart for Disney's Animal Kingdom, home to more than 1,700 animals from250

species and sprawling across 500 acres of lush landscape, it is the largestanimal-themed park in the world! DINOSAUR, Expedition Everest, It's ToughTo Be a Bug, and the Kilimanjaro Safaris are just a few of the attractions youdon't want to miss!551 North Rainforest RoadThis morning is reserved for the Southeastern HS Choir's Disney Performing ArtsOn Stage Performance (pending acceptance and scheduling by DisneyPerforming Arts On Stage).

4:00 PM Depart for home. (5 hours have been allotted for drive plus 1 hours for breaks,and dinner on your own.)

10:00 PM Arrive in Savannah, Georgia at your hotel to check in for the evening.Fairfield Inn & Suites Savannah -1-95 South (or similar)

**A Bob Rogers Travel Representative will meet you here to assist with check-in. **

SUNDAY, JUNE 47:00 AM Breakfast included at the hotel.8:00 AM Board coaches for home (10 1/2 hours have been allotted for drive time, plus 3

hours for lunch and dinner on your own and breaks).9:30 PM Arrive at Southeastern High School.

THANK YOU FOR TRAVELING WITH BOB ROGERS TRAVEL.WE HOPE YOU HAVE MADE MANY SPECIAL MEMORIES!!

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School Choir

Payment #1 - Due May 16,2016

Last Name:Last Name:Last Name:_Last Name:Last Name:_Last Name:

First Name:First Name:First Name:First Name:First Name:First Name:

Student ParticipantChaperone/SiblingChaperone/SiblingChaperone/SiblingChaperone/SiblingChaperone/Sibling

Payment Due: $50.00 for each personPayment Made: $

Check # Cash Money OrderChecks Payable to 'Southeastern Local School District'

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School ChoirPayment #2 - Due September 1, 2016

Last Name:_Last Name:Last Name:Last Name:Last Name:Last Name:

First Name:_First Name:_First Name:First Name:First Name:First Name:

Student ParticipantChaperone/SiblingChaperone/SiblingChaperone/SiblingChaperone/SiblingChaperone/Sibling

Payment Due: $170.00 for each personPayment Made: $

Check # Cash Money OrderChecks Payable to 'Southeastern Local School District'

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School ChoirPayment #3 - Due November 1, 2016

L a s t N a m e : F i r s t N a m e : S t u d e n t P a r t i c i p a n tL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n g

Payment Due: $170.00 for each personPayment Made: $

C h e c k # C a s h M o n e y O r d e rChecks Payable to 'Southeastern Local School District'

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School Choir

Payment #4 - Due January 3,2017

L a s t N a m e : F i r s t N a m e : S t u d e n t P a r t i c i p a n tL a s t N a m e : F i r s t N a m e : _ _ C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : _ F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : _ _ C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n g

Payment Due: $170.00 for each personPayment Made: $

_ C h e c k # _ C a s h _ M o n e y O r d e rChecks Payable to 'Southeastern Local School District'

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School ChoirPayment #5 - Due February 1, 2017

L a s t N a m e : F i r s t N a m e : S t u d e n t P a r t i c i p a n tL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n g

Payment Due: $170.00 for each personPayment Made: $

C h e c k # C a s h M o n e y O r d e rChecks Payable to 'Southeastern Local School District'

2017 Southeastern Orlando Trip PaymentsMarching Panthers & High School Choir

Payment #6 - Due March 1, 2017

L a s t N a m e : F i r s t N a m e : S t u d e n t P a r t i c i p a n tL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : _ C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : _ _ C h a p e r o n e / S i b l i n gL a s t N a m e : F i r s t N a m e : _ C h a p e r o n e / S i b l i n g

Payment Due: $170.00 for each person PLUS any additional money due based on the finalPayment Made: $

_ C h e c k # _ C a s h _ M o n e y O r d e rChecks Payable to 'Southeastern Local School District

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

Eligibility/Disciplinary Action AgreementStudent participants are required to be active participants of the 2016 Southeastern

Marching Panthers and/or members of the 2016-2017 High School Choirs. Students who losetheir membership in the choir or marching band will not be allowed to participate on the trip andwill not be eligible to receive a refund. It is encouraged for participants to purchase the optionalinsurance coverage to cover cancellations for any reason. If a student drops out of band/choir ordoes not fulfill their obligations with the band/choir during the 2016-2017 season they will notbe allowed to participate and the school will not be held responsible for any refund as a result ofdismissal from the band.

If any student participant breaks school student handbook rules or violates trip leaderrules and expectations, that participant may be asked to return home. As a parent, it is importantto note that this is a rare circumstance. But in the event your child breaks from the trip andviolates rules with their conduct, you will be responsible for getting your child home and acceptany school consequences that may be handed out to the student participant after the trip. It isvery important to go over rules and expectations before the trip. Students are to be reminded thatbeing on the trip is a privilege, not a right.

Please sign below that you agree to the eligibility/disciplinary action:

Student's Name:

P a r e n t S i g n a t u r e : D a t e : _

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

ADULT CHAPERONE INFORMATION FORM(One form for each chaperone)

L A S T N A M E : F I R S T N A M E : _

STREET ADDRESS:

C I T Y : Z I P :

HOME PHONE:

MOBILE PHONE:

WORK PHONE:

EMAIL:BEST METHOD(S) TO CONTACT YOU (please circle or fill in the following):M a i l E m a i l H o m e P h o n e M o b i l e P h o n e W o r k P h o n e

As chaperone I am a:P a r e n t / R e l a t i v e o f ( s t u d e n t s n a m e )

Relationship Age of Relative (must be 21 to be a chaperone):

Chaperone AgreementI agree to participate in the 2017 Southeastern Orlando Field Trip as a chaperone. I

understand that the trip rules as outlined above and agree to follow school protocol regarding thistrip. I also understand that no fundraising efforts will go towards the cost of chaperones going onthe trip and that chaperone money is due at the same time as the students. If accepted as achaperone, I agree to ride the bus to the location and actively serve as a chaperone for theduration of the trip including following the trip itinerary and assisting with student participantsupervision.

C H A P E R O N E S I G N A T U R E : D A T E :

T R I P L E A D E R S I G N A T U R E : D A T E :

H I G H S C H O O L P R I N C I P A L S I G N A T U R E : D A T E :

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2017 Southeastern Orlando Field Trip ContractMarching Panthers & High School Choir

SIBLING INFORMATION FORM(One form for each person)

LAST NAME: FIRST NAME:

STREET ADDRESS:

CITY: ZIP:

HOME PHONE:

MOBILE PHONE:

I am a sibling of (student participant's name).

Please sign below confirming that if your child is under the age of 21, they agree to travel underyour parent supervision as part of this trip.

Parent Signature^ Date:

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STUDENT/ADULT PERMISSION & MEDICAL RELEASE FORM

Consent to Trcurel

_, give permission for(parent or guardian) (name of participant)

to travel with(name of o■rganization)

to(trip destination)

The group will depart on(departing dare)

and return on(returri date)

In the case of an emergerKy> please contact(erne?rgencv connkx and i'elation to psarticipant.)

at(phone number)

or(second phc:>ne number)

Consent to eceCre Trea tucent

As parent or guardian of(name of student)

I authorize treatment of the above mentioned student by a qualified physician or nurse in the event thestudent would require medical treatment. I understand that should a serious or life-threatening medicalemergency arise, initial treatment of the student may be rendered by an individual, trained in first aid, if inthe opinion of that individual, delay might endanger his/her life, cause disfigurement or undue comfort.On the Medical Information Form I have listed any allergies, ongoing medical treatment, or medicalproblems which might influence treatment of the student I will be responsible for charges incurred forthe student's treatment. This permission is granted with the understanding that except in a seriousmedical emergency, a reasonable effort will be made to inform me prior to treatment.

Contact ZnfornaitCon

A u t h o r i z e d S i g n a t u r e D a t e

Address

Home Phone

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MEDICAL INFORMATION FORM

Student'sName

( F i r s t ) ( M i d d l e ) ( L a s t )Home Address

(Street)

C i t y S t a t e Z i p

H o m e T e l e p h o n e N u m b e r C e l l P h o n e N u m b e r( A r e a c o d e ) + ( N u m b e r ) ( A r e a c o d e ) + ( N u m b e r )

S t u d e n t ' s d a t e o f b i r t h R e l i g i o n ( o p t i o n a l )

Medical problems or allergies which might influence medical treatment (If none, please state "none known").

If student is under physician's care for ongoing medical treatment, please complete the following:

Medication(s)

Condition

P h y s i c i a n ' s N a m e P h y s i c i a n ' s T e l e p h o n e N u m b e r .

XnSu.ra.nce Znf-or^^tion

Name of Primary Insured

Primary Insured's Employer.

Insurance Provider

G r o u p N u m b e r M e m b e r N u m b e r*Please copy insurance card and card holders ID on the back of this form or attach to this sheet.


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