Series 604.7.2.7P - International Field Trip - Student Medical Treatment Information and Permission
Adopted: October 2016
Staff: 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 that you complete a separate consent or waiver form which is included and must be returned with this form.
Parent/Guardian: Complete this form and return 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 #
□ 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 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.
Reporting Serious Incidents
Pursuant to Minnesota state law, District 196 requests that you report to relevant school staff any hospitalizations due to accidents, illnesses or deaths that occurred during 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, etc. I understand District 196 also reserves the right to cancel programs due to insufficient participation or due to other circumstances beyond its control. I acknowledge that cancellation fees for such circumstances will be in effect.
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 student participates in the trip. I agree that District 196 may terminate 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.
I understand it is my responsibility to request and acquire proper visas, re-entry papers, or any other documents required for 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 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: ___________________________________________
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: _____________________________________________
Send completed form to the Director of Secondary Education