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604.7.2.7P - International Field Trip - Student Medical Treatment Information and Permission

604.7.2.7P - International Field Trip - Student Medical Treatment Information and Permission

Adopted: October 2016
Revised: November 2021


Download 604.7.2.7P - International  Field Trip - Student Medical Treatment Information and Permission


Staff: Complete this section and attach additional field trip details as necessary


Details and dates of international field trip:




□If this box is checked, the field trip location/facility requires the completion of a separate consent or waiver form which must be returned with this form.


Parent/Guardian: Complete this form and return to your child’s teacher by:                                    

The information is required for trip participation. Failure to provide the requested information may result in the loss of eligibility to participate. The information will be shared with school staff and officials administering the trip and will be used, as necessary, to respond to your child’s needs.


Student's name                                                   Grade                                                                                    Birthdate



Student address (street, city, zip code)



Parent or guardian name                                                                                   Email address



Parent or guardian telephone number(s) with area code   (home)                          (work)                                (cell)



Name and telephone numbers of neighbor or relative



Insurance provider                                                        Policy #


Medical Information

□ Yes                         □ No             Does your child have any known allergies? If yes, what?                                                                       

□ Yes            □ No          Does your child have an EpiPen?

□ Yes            □ No          Does your child take medication? Please list:



Medication name                                   Dose                             How often                                                                 Reason



Medication name                       Dose                             How often                     Reason


***Please remember to send all required medication in original container***

□ Yes    No    Does your child have any physical factors, surgeries (within the last year) or other health concerns that might affect your child’s activity or would be necessary for a physician to know when caring for your child? Please list:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      


Date of last tetanus shot (month/day/year) _____/______/_____


Medical Treatment Authorization (In case of illness, injury or an emergency, it might be necessary to treat or seek care for your child before staff can contact you.) By signing below, I (student’s parent/guardian or adult student age 18 or older*) agree that Independent School District 196 (District 196) shall have full authority to take actions it deems necessary to safeguard the health, safety and well-being of my student during the field trip. Such authority shall include authorization to, when necessary:

·   Administer treatment, first aid and medications, including those identified above,

·   Secure medical treatment (including surgery) from local medical personnel and medical institutions, and/or

·   Send my student home for treatment.

I confirm that, to the best of my knowledge, my student is physically and mentally able to participate in the field trip and its activities. Additionally, before my student can participate in the field trip, I understand I may be required to supply additional medical information.


Waiver of Claims

I understand and am aware that this field trip involves a risk of injury or illness to my student, including but not limited to the risk of contracting COVID-19 and/or being quarantined before, during or after the trip. I freely and voluntarily assume and accept this risk for myself and on behalf of my student. By signing below and in consideration of District 196 allowing my student to take part in this activity, I agree for myself and on behalf of my student to waive all liability against the District 196, its employees and volunteers with respect to any and all injury, disability, death, inconvenience, expense or damage to person or property that occurs as a result of my student’s participation in the field trip. This Waiver releases claims based on ordinary negligence, but does NOT release claims based upon the school district’s gross negligence or willful or wanton misconduct.


Expectations, Guidelines and Termination of Participation

I have read and reviewed the attached “Overnight Field Trip Expectations and Guidelines” and have discussed them with my student. I understand that my student is expected to comply with District 196 behavior expectations, program standards and all local laws, and that my student may be prohibited from attending the trip, sent home during the trip and/or subject to District 196 consequences for failure to do so.


I agree to cover all resultant expenses and acknowledge that no refunds will be granted if my student must return home or is precluded from attending the trip for misconduct.


Reporting Serious Incidents

I understand that pursuant to Minnesota state law, District 196 requests that I report to relevant school staff any hospitalizations due to accidents, illnesses or deaths that occurred during my student’s participation in an international trip sponsored by the school.


Alteration of Program or Cancellation by District 196

I acknowledge that District 196 reserves the right to alter the itinerary and to adjust costs and cancellation fees to reflect changes of any sort beyond the control of District 196, such as any changes in exchange rates, airline costs, pandemic related matters, etc. I understand District 196 also reserves the right to cancel the trip due to insufficient participation or due to other circumstances beyond its control, including, but not limited to, circumstances related to the COVID-19 pandemic. I acknowledge that any applicable cancellation fees for such circumstances will be in effect and that refunds may not be available in the event of cancellation. I understand that it is my sole responsibility to insure against the risk of loss, including the risk of trip cancellation and I will not hold the school district responsible for any financial loss associated with trip cancellation.


Failure to Pay or Complete/Obtain Necessary Paperwork

I understand that I am responsible for paying necessary costs/fees for this trip and may be required to complete additional paperwork before my student participates in the trip. I agree that District 196 may terminate my student’s participation in the field trip for failure to make any required payments on time or to complete required paperwork on schedule. In such cases, cancellation fees remain in effect and refunds may not be available.


I understand it is my responsibility to request and acquire proper visas, re-entry papers, proof of vaccination or any other documents required for my student to visit and return from the foreign destination. I acknowledge that no refunds will be made for the failure to acquire proper travel documents.



By signing this form, I acknowledge that I have read and agree to the above terms and give permission for my student to attend and participate in the field trip. I understand that I am under no obligation to give permission for my student to attend the field trip and, if I choose not to give permission, my student will be expected to attend school on the day(s) of the field trip.


Name of parent/guardian name/adult student (print): __________________________________

Signature of parent/guardian/adult student: ___________________________________________

*All references to “my student” shall be understood to mean “me” or “I” with respect to an adult student signing this form.



For Staff Use Only – International Field Trips

For trips involving international travel with students (including to Mexico and Canada) in which the district has a written agreement with the program provider, please complete and send this form to the Director of Secondary Education if the above student 1) was hospitalized due to an accident; 2) became ill; or 3) died while participating in the trip.


Date of hospitalization due to accident/illness/death: _____________________________________


City/location of hospitalization/illness/death: ____________________________________________


Description of incident (reason for hospitalization, type of illness, etc.): ____________________




Name/type of travel abroad program and program provider name: __________________________



Name of staff person completing the form (print): ___________________________________________


Signature of staff person completing the form: _____________________________________________


Date: __________________________________

Send completed form to the Director of Secondary Education