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Series 604.7.2.4.1P - Overnight Field Trip - Student Medical Treatment Information and Permission

 

Staff: Attach additional field trip details as necessary

Details and dates of overnight field trip:                                                                        

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

□ If this box is checked, the field trip location/facility requires that you complete a separate

    consent or waiver form which is included and must be returned with this form.

 

 

Parent/Guardian: Return completed form to your child’s teacher by:                                     

 

                                                                                                                                      

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 action it deems necessary to safeguard the health, safety and well-being of 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 student home for treatment.

I confirm that, to the best of my knowledge, student is physically and mentally able to participate in the field trip and its activities. Additionally, before 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 to student. I freely and voluntarily assume and accept this risk for myself and on behalf of student. By signing below and in consideration of District 196 allowing student to take part in this activity, I agree for myself and on behalf of student to waive all liability against the District 196, its employees and volunteers with respect to any and all injury, disability or damage to person or property that occurs as a result of student’s participation in the field trip. This Waiver releases claims based on ordinary negligence, but does NOT release claims based upon gross negligence or willful or wanton misconduct.

Termination of Participation

I understand that, during the field trip, student is expected to comply with District 196 behavior expectations, program standards and all local laws, and that student may be sent home and/or subject to the District 196 misbehavior consequences for failure to do so.

If student is returned home for misbehavior, I agree to cover all resultant expenses to return the student home and acknowledge that no refunds will be granted.

Permission

By signing this form, I agree to the above terms and give permission for student to attend and participate in the field trip. I understand that I am under no obligation to give permission for student to attend the field trip and, if I choose not to give permission, 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:                                                                 

Procedures/604.7.2.4.1P/10-10-16