School Activity/trip Permission Form printable pdf download

School Activity/Trip Permission Form

Name of School: _________________________________________________________ Date:__________________

Name of Student:_____________________________________________

Date of Field Trip: ___________________ Duration of Trip:___________ until ____________ Trip Cost: __________

Destination and Purpose of Field Trip (including any activities in which your child will be participating):

________________________________________________________________________________________________

I/We as Parent(s) or Guardian(s) of ____________________________________, do hereby give permission for my child to participate in the

above referenced field trip and/or school activity. I understand that the school will make arrangements for transportation and supervision

during the field trip activity.

I understand that this trip is an optional activity and is not required for credit in any course the student is taking. I also understand that the

student’s grade in the course, which is related to this trip, will not be affected by my child’s participation or lack thereof. The student will be

allowed reasonable time to complete all course work as outlined by his/her teachers as a result of being out of class for the above referenced

activity.

I do understand that non-refundable deposits and contractual fiscal obligations will be subject to forfeiture in the event of a National Security

Alert- one which would make it prudent to cancel the activity for specific locations or the entire United States.

I do understand that there are always some risks involved in any type of activity which occurs during transportation to and from the activity and

during the activity itself. I will emphasize to my child the importance of his/her orderly and cooperative behavior during the trip and activity. I

further agree to release and hold the Davidson County Board of Education as well as their employees, administrators, agents, trustees, and

board members harmless from any and all liability for any damages or losses, including acts of negligence, incurred by my son/daughter

through their participation in this activity.

_____________________________________________________

________________________

Parent’s/legal guardian’s signature

date

Medical Emergency Information

Name of parent to contact in an emergency ___________________________________________________________

Work Phone # _______________________ Home Phone #_____________________ Other # ___________________

Does your child have allergic reactions to any medications? ________ If yes, please list _______________________

______________________________________________________________________________________________

Are there other special medical conditions or instructions (including the administration of any medication during the

trip) concerning your child’s health that needs to be brought to the teacher’s attention? ________

If so, I will send necessary medicine clearly labeled with instructions.

Comments: ____________________________________________________________________________________

Medical Authorization

I do further authorize any physician or hospital to render medical care and treatment which may be needed by the above named

student without our specific permission or authorization.

Please check one of the two statements below:

_______

I have insurance coverage for my child (name of carrier and policy # are requested) and I give permission for

him/her to be given emergency treatment in case of an accident or illness.

Health Insurance Carrier _____________________________________________ Policy # _____________________

_______ I do not currently have insurance coverage for my child, but give permission for him/her to be given emergency

treatment in case of an accident or illness. I will assume all financial responsibility for any services rendered.

Parent Signature __________________________________________________ Date: _____________________

(confirming medical information listed above)

(OPTIONAL) NOTARIZATION

(Some hospitals/doctors may not treat children if their condition is not serious/life-threatening without the notarization.)

: Sworn and subscribed to before me by

TO BE COMPLETED BY THE NOTARY PUBLIC

______________________________________, on _______________________________.

(Stamp Here)

_____________________________________ My commission expires: ________________

Signature of Notary

School Activity/trip Permission Form

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