Athletic Team Cross-State Travel Permission Slip

Student Information

Student Name:

Grade:

Team/Sport:

Trip Details

Destination (State/Location):

Date(s) of Trip:

Departure Time:

Return Time:

Medical Information

Allergies/Medical Conditions:

Emergency Contact Name:

Emergency Contact Phone:

Parent/Guardian Consent

I give permission for my student to travel with the athletic team across state lines as described above.

Parent/Guardian Signature

Date