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Safety Patrol Trip Registration

Item #: SAFETY-PATROL-TRIP

**I hereby give my consent to have my child (named above) participate in the Annual School Safety Patrol Trip to Washington, D.C. June 1 through June 4, 2012. NOTE: The AAA East Tennessee Safety Patrol Trip to Washington is sponsored and organized solely by AAA East Tennessee and is not an official school function. I hereby release AAA East Tennessee, my child's board of education, the Parent-Teacher Association, the police departments accompanying the trip, and all other agencies, excluding bus carriers which have liabilities as common carriers, from liability which may arise due to accident, sickness, supervision or any other cause. I understand that plans for my child are to leave his/her city on Friday, June 1, 2012 and return Monday, June 4, 2012.
I also hereby grant permission for my child to receive emergency medical treatment from any licensed medical physician or dentist and from licensed registered nurses.

Price: $415.00

Quantity Required

Child's Full Name Required
Child's Address (street, city, state, zip) Required
Child's Gender Required

Male
Female
School Name Required
School City Required
Parent/Guardian Full Name Required
Parent/Guardian Phone Number (999-999-9999) Required
Parent/Guardian Email Optional
Chaperone Required

Yes, I am a Chaperone
No, I am not a Chaperone
List Allergies Optional
Date of Last Tetanus Shot (mm/dd/yyyy) Required
Brief description of medical condition and medically required diet Optional
Do you give consent to have your child participate in the trip?** Required

Yes, I give consent
Full name of person to be beneficiary of accident insurance policy Required
Relationship to Patroler Required
Address of beneficiary Required