Attachment B
CENTENNIAL SCHOOL DISTRICT
FIELD TRIP PERMISSION FORM
PARENT/GUARDIAN HOLD HARMLESS AND ACKNOWLEDGEMENT OF RISK AGREEMENT
Dear Parent or Guardian:
In anticipation of your student’s upcoming field trip, we provide the following information. This agreement is entered into with the full understanding that the field trip may involve activities, which, by their very nature, may be hazardous, and under circumstances which render individual supervision difficult. Fully acknowledging this, your signature gives permission for your son/daughter to attend the field trip.
Sponsor/Teacher Name Lenox/Miller/Goppold School Log College Middle School
Name of Student Grade/Homeroom D.O.B.
Address City State Zip
Description of Trip: Trills and Thrills- Six Flags Great Adventure
Date: 5/30/14 Time: 6:00 a.m. to 9:30 p.m.
In compliance with District policy, no student is permitted to carry any form of medication unless authorized in writing by the District. Arrangements for transport of medication essential to your student's health should be made with the school nurse. If your student will need any medication during the trip, you are encouraged to accompany your student.
Parent or guardian of student requiring daily medication must check one of the following:
- ______I understand that my student will omit his/her daily scheduled medication on the day of the trip.
- ______My student may take his/her regularly scheduled medication upon returning to school.
- ______If space allows, I will accompany my student on the trip, at personal expense, and I will administer his/her medication.
4. My student may take his/her regularly scheduled medication during the trip, under supervision of a staff member.
If you check #1 or #2 please provide doctor’s note of confirmation to the school nurse ten days prior to the scheduled field trip.
The following information must be supplied for all students attending this field trip:
A PARENT OR GUARDIAN CAN BE REACHED AT THE FOLLOWING TELEPHONE NUMBERS ON THE DAY OF THE ACTIVITY:
Mother or Guardian Father or Guardian
Home Work Home Work
PERSON TO CALL IF A PARENT OR GUARDIAN CANNOT BE REACHED:
Contact #1 Name Phone
Contact #2 Name Phone
PHYSICIAN Name: Phone
ANY SERIOUS ALLERGIES, MEDICAL CONCERNS OR DIETARY ISSUES:
INSURANCE INFORMATION: CARRIER POLICY NUMBER
In case of illness or emergency, I authorize the officials of Centennial School District to contact directly the persons named on this form. In the event parents, physician, or other persons named on this form cannot be contacted, the school officials are authorized to take whatever action is deemed necessary for the health and safety of my student. I also give my permission that my student may be taken to the hospital and treated in case of emergency
Date Signature of Parent or Guardian
Please Print Name of Parent or Guardian
81
Attachment B
CENTENNIAL SCHOOL DISTRICT
STUDENT TRIP INFORMATION
Date: 4/1/2014
Dear Parent:
This notice is to inform you that your son’s/daughter’s class/organization is scheduled for an educational trip. The details of the trip are as follows:
Destination: Trills and Thrills: Six Flags Great Adventure
Date: 5/30/2014
Departure Time: 6:00 a.m.
Return Time: 9:30 p.m.
Group: Log College Middle School Music Students
Cost: $90
Please indicate receipt of this letter and your being informed that your son/daughter will have the opportunity to participate in this trip by signing the attached form and returning it to school by
Date: 4/1/2014 Teacher: Lenox/Miller/Goppold
Special Notes:
1. The Centennial School District is not responsible for services not delivered by non-school contractors/firms.
2. The Centennial School District assumes no liability for activities conducted as a part of a school trip.
Student’s Name:
Trip
Date:
This will acknowledge receipt of information regarding the aforementioned educational field trip and permission for my child to participate.
Parent Signature: Date:
This will acknowledge receipt of information regarding the aforementioned educational field trip. I DO NOT give permission for my child to participate.
Date Signature of Parent or Guardian
Please Print Name of Parent or Guardian
81