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FORM E3 Student Group: Yr 10 IYA Bronze Assessment

(Student's Name) _____________________ (Homeroom) _____ has my permission to participate on a field trip to Pak Chong, IYA Bronze Trekking Assessment The students are travelling by Mini Van and will leave the school at approximately 0745am on Either: Monday 30th – Tuesday 31st May Or Thursday 2nd June – Friday 3rd June 2011 and will return at approximately 1700hrs

The field trip will be under the supervision of the following NIST staff members: Jason Reilly & Graham Wardle along with 6 additional NIST Staff Student's emergency home or contact numbers: Home _________________________ Mobile _________________________ Business ________________________ Mobile _________________________ Please respond to the following questions as appropriate: 1. Is the student on any personal medication? Yes No If yes – Detail the medication, dosage, time etc. ____________________________________________________________ ____________________________________________________________ 2. Does the student have any dietary restrictions? Yes No

Details ______________________________________________________ 3. Detail the swimming ability of your child Non swimmer Beginner Moderate Strong

4. To the best of your knowledge, has your son/daughter been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may be contagious or infectious? YES/NO

If YES, please give brief details _________________________________________

Student Commitment I understand that as a student of NIST I am expected to abide by all NIST rules regarding possession and use of tobacco products, alcohol and other non prescriptive drugs as outlined in the Student Handbook. The consequence of not abiding by these rules may involve me being sent home from the field trip at my family’s expense and/or suspension. A worse case scenario may even involve recommended expulsion. I will also display common courtesy in behaviour, language, attitude and manners on this trip as well as adhere to any other guidelines required by the chaperones. Student Name: ………………………………….. Year: ……………….. Signature: …………………………… Date: ……………………….

Please Turn Over

Provided all due supervision by teachers is properly organised and carried out, I recognise as parent/guardians of the above student that neither the school nor NIST staff members will be held responsible for any accident or other unexpected event, nor for events arising from the above student disobeying instructions. I agree that if the student fails to follow the directions of the staff that I will arrange to collect my child from the field trip / activity site at my own expense. In addition, I give my permission for any necessary medical attention to be administered as deemed necessary if I cannot be contacted beforehand. Overnight Field Trips are governed by the Rules and Regulation of the Ministry of Education.

PARENT / GUARDIAN'S NAME (PRINT) _____________________________________

(Signature) _________________________

(Date) _________________________

***Field Trips are a part of the school curriculum. All students are encouraged to participate. Parents/students who have committed to a field trip will be invoiced for all non-refundable costs associated with the trip in case of absence.***

The New International School of Thailand has a supplementary Personal Accident/ Medical Cover Policy that applies to any official school trip that includes an over-night stay. On these occasions (overnight trips) the Medical Cover is 160,000 baht for short term emergency medical expenses, 200,000 Baht for death/disability and 50,000 baht for emergency medical evacuation. Parents are strongly advised to check whether these amounts are satisfactory for their personal circumstances and may arrange additional insurance at their own cost if they so desire. Any amounts in excess of the above must be paid for by the parents. The signing of the consent form indicates that you as a parent understand that the school’s liability is limited to the above sums. with ________________________________________________(insurance company), Policy No._____________________________________________________________ Policy renewal date._____________________________________________________ Return this completed form to: Khun Pare in the Secondary Office by: FRIDAY 6th May 2011