Parent Permission For Field Study Activities Form printable pdf download

ST. JOHNS COUNTY SCHOOL DISTRICT

PARENT PERMISSION FORM FOR FIELD STUDY ACTIVITIES

School:____________________________________________________________________________________________

I/We, the parents/guardians of the student named below, understand the nature of the activity being planned to:

_________________________________________________________________on_______________________________

(DATE)

Time: Leave: ___________ Return: _____________We understand transportation will be by:

________________________________________________________________________ at a cost of $______________

(MODE OF TRANSPORTATION)

We acknowledge our student is in good physical health and the Study does not pose a health hazard to my student. We also

understand in times of national emergency or any other time when it is in the best interest of the health, safety and welfare of

students and employees, the School Board may revoke its approval assuming no liability for reimbursement of costs or expenses

incurred by the cancellation of any activity.

I/We hereby grant permission and give my/our consent for my student to (1) be treated by any qualified nurse, physician, or surgeon

as may be deemed necessary by the District, its agents, servants, or employees during the activity; (2) be administered medication

and/or emergency first aid care as may be necessary or appropriate; and (3) receive treatment in hospitals, medical offices, or

elsewhere in the event of accident or illness. To assist in that medical care or treatment, I/we represent that the medical information

supplied on the Medical Information Form and or the School Health Card is true and accurate. In the event of an injury requiring

medical attention,

I/We understand and agree that neither the District nor its agents, servants, or employees are responsible for

obtaining, or for the result of any medical or emergency treatment rendered or supplied to my student. I/We will hold the District and

its agents, servants, or employees harmless and indemnify them from any claim, cause of action or demand arising out of any form of

or the lack of medical or emergency treatment rendered to my student.

In the event that a student must return to school independently for reasons of health, accident, failure to conform to rules established

by the teacher in charge, etc., we agree to accept full responsibility for and to pay for the cost of medical care, transportation and other

incidental expenses. This permission slip also serves as a contract that the student and parent(s) understand and agree to the guidelines

from each teacher as to making up missed assignments.

My student, by his/her signature hereto, fully agrees and consents to the foregoing with permission to participate in the listed field

study.

Student’s Name (Print): ______________________________________________

____________________________________________________ ___

_____________________________

Signature of Student

Date

_______________________________________________________

_____________________________

Signature of Parent/Guardian

Date

________________________

______________________

_____________________________

Cell Phone

Work Phone

Home Phone

Emergency contact, if parent unavailable _____________________

Phone _______________________

Family Physician ________________________________________

Phone _______________________

Health Insurance Provider _________________________________

Policy# ______________________

If the student requires medication during this activity, and or there is information of which sponsors should be aware, I

understand I am obligated to complete the Medical Information Form (obtained from the activity supervisor) and provide

the medication to the personnel trained to administer the medication.

Board Approved August 13, 2013

Parent Permission For Field Study Activities Form

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