Parent/Legal Guardian Permission Form For Field Trip Participation

Dear Parent or Legal Guardian,

Your son/daughter, guardianship, is eligible to participate in a school-sponsored activity that requires transportation to a location away from the school site. This activity will take place under the guidance and supervision of employees from _________________________School. A brief description of the activity follows: Activity: Destination: Designated Supervisor of Activity: Date and Time of Departure: Date and Anticipated Time of Return: Method of Transportation: Student Cost: If you would like your child to participate in this event, please complete, sign and return the following statement of consent and release of liability. As parent, or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student.

I hereby consent to participation by my child, , in the event described above. I understand that this event will take place away from school grounds and that my child will be under the supervision of the designated school employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.

(Check ONE of the following that applies to your child) My child is ____under 8 years of age or 80# and needs to be in a car seat OR my child is ____over 8 years of age or 80 # and does not require a car seat.

I give my permission for my child, in case of an emergency, to be taken to a physician or hospital by either a parent in charge or by school personnel. I understand that every effort will be made to contact me. If I cannot be reached, however, I hereby give permission to the physician selected by the teacher in charge or adult chaperone(s) to hospitalize and secure proper treatment (including surgery) for my son/daughter.

Parent’s or Legal Guardian’s Signature Date

Accident/Hospitalization Policy Name: Policy Number: Emergency Contact Phone Number:

Student Name:

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