Form - 2320f1 Field/activity Trip - Parent/guardian Permission Form

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Policy Series: 2000: Instruction
Form – 2320F1 
 
 
ISSAQUAH SCHOOL DISTRICT
FIELD/ACTIVITY TRIP – PARENT/GUARDIAN PERMISSION FORM
ASSUMPTION OF RISK/ PERMISSION TO PARTICIPATE
As a parent or guardian of a student requesting to voluntarily participate in a field trip, I hereby
acknowledge that I have read, understood and agreed to the following:
Field Trip Destination ____________________________Purpose________________________________
I hereby give my permission for ______________________________ who attends__________________
(Print Student’s Name)
(School Name)
to participate in a field trip on (date) _________________. Time involved: From________To__________
Type of Transportation:
______District Vehicle by district staff
______District is not providing transportation. Parents arrange transportation for their student
______Private Vehicle by district staff
______Private Vehicle by Volunteer/Parent (volunteer driver checklist on file)
______Other (e.g. – walk, metro bus, commercial: Description _________________________________)
Student’s address__________________________________________________ City ________________
Parent’s Phone: Home __________________ Cell_________________ Student Birthdate_____________
Family Physician:_______________________________ Phone #___________________________
Medical conditions, medication information or allergies the district should be made aware of:
_____________________________________________________________________________________
In the event of an emergency, I wish the following person to be notified in case I cannot be contacted:
Name______________________________________________ Phone #___________________________
I understand that all school and district policies are in effect on this trip.
I understand that this is a school sponsored activity and is governed by the Policies and Procedures of the
Issaquah School District.
I acknowledge that this activity entails known and unanticipated risks which could result in physical or
emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks
simply cannot be eliminated without jeopardizing the essential qualities of the activity. I agree to hold and save
harmless the Issaquah School District, its School Board and Employees, and assigns for any claims, suits or
damages (including but not limited to defense and indemnification) which might result from my child participating
in the above-described event/activity.
I certify that my child has no medical or physical conditions which could interfere with his/her safety in this
activity.
I authorize qualified emergency medical professionals to examine and in the event of injury or serious
illness, administer emergency care to the above named student. I understand every effort will be made to contact
me to explain the nature of the problem prior to any involved treatment.
In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my
student, neither s/he nor the ISD district assumes financial liability for expenses incurred because of the accident,
injury, illness and/or unforeseen circumstances. I understand that I am responsible for any costs associated with
an accident or injury. My child has medical/accident insurance:
Yes ______
No______
To be completed by ISD staff
[
] Required attachments checked below:
Extended Trip Itinerary_____
Challenge/Ropes Course Release _____
Water Activity Release_____
Being fully informed as to these risks, I hereby consent to my child participating in this Field Trip.
Signature of Parent/Guardian
Date
Work/Daytime Phone
Adopted:  12/92 
Previous Revisions: 3/16/05, 9/2/05 
Last Revised: 08/06/09 

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