Form 2320f-5 - Student Trip Permission Form
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1Form 2320F-5
Instruction
1/1
STUDENT TRIP PERMISSION FORM
Name of Student: ______________________________________________________________
Place/Activity:
Supervisor: __________________________
Date(s) of Trip:
Time of Departure:
Time of Return: ________
Transportation (check appropriate category – all drivers require completion of 2320 F-4)
District Vehicle/Employee Driver
District Vehicle/Adult Volunteer Driver
Private Vehicle/Employee Driver
Private Vehicle/ Adult Volunteer Driver
Public Transportation
Private Carrier:
Walk
Other:
Medical Information: In the space below, please list special health problems we need to be
aware of (severe reaction to bee stings, severe food allergies, asthma, diabetes, seizures, etc.),
medications being taken or special diets needed:
Hold Harmless: Although I understand that Bellingham School District will make every
reasonable effort to provide a safe environment, I am fully aware of the special dangers and risks
inherent in my child’s participation in this activity. Further, I accept full responsibility for the
behavior of my child during this activity and agree to hold harmless the school, school district,
district employees, volunteers and board members for any injury or illness of any nature
whatsoever associated with my child’s participation in this activity, negligence not withstanding.
In the event of an injury or illness, I understand that reasonable effort will be made to contact the
parent immediately. However, I am aware that if the injury or illness appears serious and the
parent cannot be reached, the adult in charge will secure emergency medical care as needed.
Being fully aware of the risks, I hereby give my consent for the above named student to
participate in the above mentioned activity.
Parent/Legal Guardian Signature
Date
Student Signature
(for grades 6-12)
Parent/Guardian Printed Name
Phone Number: Home/Cell/Work
Emergency Contact Person
Emergency Contact Phone Number
Doctor’s Phone Number
Name of Preferred Doctor
Bellingham Public Schools
Bellingham, Washington
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