Seattle Public Schools
Parent/Guardian Authorization for Day Field Trip
Directions:
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.
Students:
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 & Acknowledgement of Risks” section on page 2.
2) Complete the “Medical Authorization” section on page 2.
School Name:
Student Name:
Date(s) of Trip:
Destination:
Purpose(s):
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.)
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walking
school bus
public transit
Other
_________________
Students will leave from: _________________________________________ at ____________________.
(where)
(time)
Students will return to: ___________________________________________at about _______________.
(where)
(time)
Chaperone(s) in Charge:
___________________________________________________________________________
Chaperone/Student Ratio: __________________________ (max. ratio for K-5, 10:1; max. ratio for Grades 5+, 15:1)
STUDENT AGREEMENT
While participating in this field trip, I understand I will be a representative of SPS and my school 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
Date