Field Trip Permission Form For Parents/guardians Form - Roanoke City Public Schools (Page 2 of 2) in pdf

Field Trip Permission Form For Parents/guardians Form - Roanoke City Public Schools Page 2

ROANOKE CITY PUBLIC SCHOOLS

FIELD TRIP PERMISSION FORM

HEALTH INFORMATION

(Please print all information)

Name ___________________________________

I.D. # ___________________________

Age _______________________

Date of Birth __________________

Address _________________________________________________________________________

City ________________ State ___________ Zip Code ________ Telephone No. ______________

Names of custodial parents/legal guardians______________________________________________

Parent/Guardian work phone number _______________ Cell/Beeper No. ______________________

Parent/Guardian work phone number ________________Cell/Beeper No. _____________________

Alternate contact name and phone number if parents/guardians cannot be reached

________________________________________________________________________________

List any medical conditions/allergies, dietary restrictions, etc. of which school staff should be aware:

________________________________________________________________________________

Please list any medication that your child is currently taking.

Any medication that is to be administered on a field trip must follow Roanoke City Public Schools

medication policy. If your child needs medication while on a field trip, you must contact your child’s

school for further instructions.

Last tetanus shot: __________________________________________________________________

Insurance

Yes

If yes, company name and policy No.: ____________________________

________________________________________________________________________________

School Insurance:

Yes

PARENT PERMISSION

I give permission and will accept financial responsibility for my child to receive medications, and/or

health procedures, and emergency medical care as needed.

Field trip destination: _______________________________________________________________

Date(s): _________________________________________________________________________

Parent Signature: __________________________

Date: ________________________________

6/19/15-Revised

Field Trip Permission Form For Parents/guardians Form - Roanoke City Public Schools Page 2