Series 604.7.2.4.1P - Overnight Field Trip - Student Medical Treatment Information and Permission
Adopted: March 1982
Revised: October 2016
|
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