Parent/guardian Authorization For International Field Trip Form


Parent/Guardian Authorization for International Field
SPS Staff:
1) Use one form per trip.
2) Complete the School Portion of form on page 1.
3) Duplicate one form per student.
4) Send a copy home for parent and student signatures.
5) During the field trip, the signed, original form must be carried by the lead chaperone and a
photocopy must be left on file in the school office.
1) Complete the “Student Agreement “on page 1.
Parent / legal guardian, if student is under 18 years of age,
or student, if at least 18 years old:
1) Complete the “Authorization and Acknowledgement of Risks” and “Medical Authorization” on page 2.
2) Complete the “ Medical Information Form” and “Medication Administration Form” on pages 3-5.
School Name:
Student Name:
Date(s) of Trip:
List of Activities:
Supervision: (Check One.)
□ Students will be directly supervised by adult chaperones on this trip at all times.
□ Students will be directly supervised by adult chaperones on this trip with the following exceptions:
Mode of Transportation: (Check all that apply.)
□ school bus □ charter bus □ scheduled airline □ boat/ferry □ train □ Other ______________________
Students will leave from: ______________________________at ____________________.
Students will return to: ________________________________at about _______________.
Chaperone(s) in Charge:
Chaperone/Student Ratio: _____________________ (maximum ratio 10:1)
While participating in this field trip, I understand I will be a representative of SPS and my community. I
understand that appropriate standards must be observed, and I will accept responsibility for
maintaining good conduct and abide by school based rules and the Basic Rules of Seattle Public
Schools – Code of Prohibited Conduct.
Student Signature


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