Field Trip Permission Form - Wattsburg Area School District

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WATTSBURG AREA SCHOOL DISTRICT
FIELD TRIP PERMISSION FORM
Teachers: Please complete the information in the shaded box.
Date of Field Trip _______________Destination of Trip __________________________________________
Departure Time from School_____________ Estimated Return Time to School ________________________
Student Cost___________________ Lunch Information ___________________________________________
Parents: Please complete this form and return it to your child’s homeroom teacher by _______________
Parents: Please indicate whether your child has any of the following health concerns:
No
Yes
Asthma
No
Yes
Inhaler Needed
Name of Medication _______________________________________________
Life-Threatening Allergy
No
Yes
to Insect Sting
Treatment _______________________________________________________
Life-Threatening
No
Yes
Allergy to Food(s)
Food(s) _________________________________________________________
Treatment _______________________________________________________
No
Yes
Heart Defect
No
Yes
Seizure Disorder
Name of Medication ______________________________________________
No
Yes
Diabetes
Name of Medication ______________________________________________
No
Yes
Allergy to Drugs
Name(s) of Drug(s) _______________________________________________
Reactions(s) _____________________________________________________
Other Health Concerns ________________________________________________________________________________________
Parents: Please list emergency contact information during the time that your child will attend the field trip.
Name _______________________________ Phone ___________________________ Cell Phone ___________________________
Name _______________________________ Phone ___________________________ Cell Phone ___________________________
If emergency treatment is required and parents/guardians cannot be notified, I give consent for emergency treatment and transport to
the nearest emergency room.
I GIVE CONSENT FOR MY CHILD TO ATTEND THE FIELD TRIP.
If your child has a medical condition that may require treatment during the field trip, please check one of the following:
I am able to attend the field trip and administer any medical treatments that my child may require.
I am not able to attend the field trip.
I DO NOT GIVE CONSENT FOR MY CHILD TO ATTEND THE FIELD TRIP.
Student’s Name ____________________________________ Grade _____ Homeroom Teacher ___________________________
Parent’s Signature ________________________________________________________________ Date _____________________

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