STUDENTS 09.36 AP.211
School-Related Student Trip Permission Slip and Medical Release Form
Student’s Name ______________________________ ____________________ __________________
Last Name First Name Middle Initial
School _____________________ Grade ________ Homeroom/Classroom ______________________
o All school-related trips for the ______________ school year; OR Field Trip Date(s) ____________________
Alternate Destination, if applicable ______________________________________________________
Mode of Transportation ___________________________Cost to Student, if applicable $_________
I hereby give permission for my child to participate in the above mentioned school-related student trip(s).
In addition, in the event of accident or sudden illness while on the school-related student trip, I authorize school personnel to contact the physician(s) listed on my child’s school enrollment data forms and authorize those physician(s) to render such treatment as may be deemed necessary in an emergency for the health of said child. In the event physician(s), parent(s), or other persons designated by the parent cannot be contacted, school personnel are hereby authorized to take whatever action is deemed necessary in their judgment for the health of said child.
Parent/Guardian’s Signature Date
Please return this form to your child’s teacher.