EDUCATIONAL FIELD TRIP PERMISSION FORM TO BE RETURNED TO TEACHER

I give/do not give (circle one) consent for ___________________________________ of class KG1F to take part
in the
Educational Field Trip planned for Little Explorers on February 24, 2014 leaving at 9:30 am and
returning at 1:00 pm.
In an emergency and if I cannot be contacted, I/we consent to the teacher in charge making a decision
in the best interests of my son/daughter regarding medical treatment and/or emergency transportation.
Contact numbers on the day of the Educational field Trip for Parent(s):
Work

_____________________________________________________________________

Home _____________________________________________________________________
Mobile _____________________________________________________________________
Contact details for family doctor:
Name_____________________________________ Telephone number __________________
Address ____________________________________________________________________
Does your son/daughter currently have (or has your son/daughter recently had) any of the following:
Asthma or bronchitis
YES
NO
Diabetes
YES
NO
Heart condition
YES
NO
Life threatening allergies
YES
NO
Fits, fainting or blackouts
YES
NO
Severe headaches
YES
NO
Other illness or disability
YES
NO
Has your son/daughter been given any specific medical
advice to follow in an emergency
YES
NO
Does your son/daughter receive any ongoing medical treatment YES
NO
Date of most recent anti-tetanus injection _______________________
If the answer to any of the above questions is yes, please give any relevant details below.

Signed .. Date ..
(Person with Parental responsibility)