Field Trip - Permission to Participate
Dear Parents or Guardian, Your childs class is going on a field trip. Please read, fill out the form, sign and return (any money if due) to your childs teacher by __________________
(Date)
I herby give my permission for ____________________________ , who attends _____________________________
(Students Name) (School) (Date and time) (Means of transportation)
To participate in a field trip going to ____________________________, on and leaving at __________________________
(Location) (Date and Time)
and returning at ________________. Transportation for this activity will be provided by _________________________ Cost of the field trip will be: ___________ Please pay by cash or check. Make check out to Schools PTA.
(Amount)
Students address: _________________________________ City: __________________________________ Students home phone #:____________________________ Date of Birth: ___________________________ Parents work #: Mother: ___________________________ Father: ________________________________ Please list any medical conditions and medication or allergy information we should be made aware of:
__________________________________________________________________________________________________
In case of an emergency who would you like us to contact if you are not available: Contact Name: Family Physician: Insurance Company: Contact Phone Number: Family Physician Phone Number: Policy Number:
I acknowledge that this activity entails known and unanticipated risks which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no medical or physical conditions which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither she/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________
Signature of parent/guardian:
____________
Date
________________
Work Phone
_________________
Home Phone
