Concordia Academy > CA Families > Documents & Links > Choir Tour Permission Choir Tour Permission Step 1 of 3 33% Student and Guardian Contact InformationThis is an overnight event. Please have images of the back and front of student’s medical insurance card ready to upload for page 2 of this form. Please have student and parent present when completing page 3 of this form.Student Name(Required) First Last Student Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeStudent Home Address(Required) Street Address City ZIP / Postal Code Student Phone (Mobile)(Required)Parent/Guardian 1 Name(Required) First Last Relationship Parent/Guardian 1 Phone (mobile)(Required)Parent/Guardian 2 Name(Required) First Last Relationship Parent/Guardian 2 Phone (mobile)(Required)Parent/Guardian Email(Required)This address will receive a confirmation email with all answers on this form. Enter Email Confirm Email Emergency Contact Name (must be different than parent/guardian listed above)(Required) First Last Relationship Emergency Contact Phone (Mobile)(Required) Insurance InformationPrimary Health Care Provider(Required)Insurance Policy #(Required)Name of Policy Holder(Required)Upload image of medical insurance card (front).(Required)Max. file size: 128 MB. Upload image of medical insurance card (back).(Required)Max. file size: 128 MB. Medical InformationAny known allergies (including drug allergies or severe allergies to animals, foods or other substances)?(Required) Yes No If yes, please describe.Date of last tetanus shotMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does your student currently take any medication?(Required) Yes No Medication student is presently taking (include dosage and reason for each medication listed):* NOTE: All prescription and OTC medication must be in original container with dosage information and will be turned in to the medical coordinator upon departure.List any physical factors or injuries that might affect student’s activity or would be necessary for a physician to know when caring for your child.Other questions or concerns.Parental Permission – If an emergency arises, it might be necessary to seek care for your child before staff can contact you. Such care can be provided only if you inital and sign the authorization below.Signature of Parent/Guardian – In case of minor illness or injury, I give my permission for the supervisor of my child to administer necessary treatment and/or first aid. In case of emergency, I hereby authorize the official representative of my child’s school or the person in charge of the program to permit a physician/hospital to administer emergency or surgical care, and I further authorize any licensed physician, medical facility or trained emergency technician to administer emergency or surgical care.(Required) Please read and complete this page with your student. Both parent and student signatures are required.Parent/Guardian: I give permission for my son/daughter to participate in this choir tour and I have read and understand all the information and rules provided. I understand that Concordia Academy will provide two teachers and eight adult chaperones who will carry out adequate and appropriate supervision during the tour and whose primary responsibility it is to keep the students safe while traveling. I also understand that unanticipated situations can arise which are not reasonably in the control of the supervising adults. Sign below to agree.(Required)Parent/Guardian: I have completed the medical release form and have listed all medications my child is currently prescribed. I understand that students may not carry prescription medications. I will provide medications needed for the trip in the original container with the dosage listed to the medical coordinator who will make sure my child receives the medication as prescribed. In the case of inhalers and emergency medication (such as EpiPen, Glucagon, Diastat), my student will carry those with them at all times. (It is recommended that the adult medical chaperone is provided with and carries a duplicate set in case of emergency.) Sign below to agree.(Required)OTC Medication(Required) I understand that students are not to carry complete packages of over-the-counter (OTC) medication in their luggage or bags. I give permission for my child to request OTC medication as needed from the medical coordinator. This includes pain reliever, cough medicine, cold and allergy relief, and digestive aids. No, please do not give my child the OTC med/s listed in the next section. Please do not administer the following OTC meds to my student:Parent/Guardian Signature – OTC Medication rules(Required)Student: I have read, understand, and agree to abide by the rules and behavior expectations for this trip. I will be accountable to my tour partners and adult chaperones and will follow the itinerary given. I understand that Concordia Academy’s policies as outlined in the 2025-26 Parent-Student Handbook extend into this tour as a school sponsored event. Sign below to agree.(Required)Student: I understand that the use and/or possession of controlled substances and weapons will result in immediate dismissal from the trip on the first available trip home, unchaperoned, and at student’s expense. Subsequent discipline will follow school policy as well as Minnesota State High School League consequences. Sign below to agree.(Required)
