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Field Trip Permission and Medical Release Form

STUDENTS                                                                                                               09.36 AP.211

School-Related Student Trip Permission Slips and Medical Release Form

Student’s Name ______________________________ _______________________ _____________

                                       Last Name                                First Name                     Middle Initial

School _______________ Grade ______ Homeroom/Sponsor/Coach _________________

o ___________________________________________________ related trips for the _____________ school year

District Approve d Athletics/Program

o Field Trip Date(s) __________________________________________________________________________

Destination ___________________________ Alternate Destination, if applicable __________________________

Is field trip                 o Overnight In-State Trip             o Out-of State Trip

Mode of Transportation _____________________________________ Cost to Student, if applicable $_______

Health and Medical Information

List Student’s Allergies: ______________________________o Food Modification on file with School Nutrition

List Student’s Health Conditions: _________________________________________o IHP on file in health unit

List all medications (prescription and over the counter--OTC) that student takes at home and during the school day. Include as-needed and emergency medications.

*Medication Name
(on label or box)

Dose Ordered

Time(s) Ordered

Taken @ School

Taken @ Home

**Written Authorization to Carry and Self-Administer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Add additional information on the back of form if necessary)

*All medications must be in the original container. Medications not authorized for student to carry and administer must be given to the staff member designated to provide health services or the supervising teacher/sponsor/coach for proper storage.

**For student to carry and self-administer: Prescription meds must have written authorization of prescribing healthcare provider and OTC medications must have written approval of parent/guardian.

Out of Town/Overnight/Out of State Field Trips Only

Student’s Healthcare Provider:__________________________________________ Telephone: _______________

Student’s Health Coverage: ______________________________________________________

(A copy of the student’s health coverage/insurance may be attached if preferred.)

I hereby give permission for my child to participate in the above-mentioned school-related student trip(s). All health information provided by me to the school for this field trip is correct and accurate to the best of my knowledge. I authorize trained school personnel to assist my child with his/her medication as my child’s healthcare provider or I have directed if needed. In addition, in the event of accident or sudden illness while on the school-related student trip, I authorize school personnel to have my child transported by EMS to the nearest hospital and authorize 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/coach/sponsor.

 

STUDENTS                                                                                                               09.36 AP.211

                                                                                                                                    (Continued)

School-Related Student Trip Permission Slips and Medical Release Form

Student Driver

THE STUDENT DRIVING A VEHICLE AND THE PARENT/GUARDIAN OF THE STUDENT DRIVING A VEHICLE MUST COMPLETE THIS FORM.

Student Driver: ______________________________________________________________

Purpose: ____________________________________ (i.e., journalism, MSU, yearbook, co-op)

Date(s) of Trip(s) ______________ Departure Time _________ Return Time _________

Destination _________________________________________________________________

Names of Principal-Designated Sponsors ______________________________________

PARENT/GUARDIAN SCHOOL-RELATED TRAVEL PERMISSION

I agree that my child, _____________________________, may leave school in an automobile on _________________, 20____, at ________________ o’clock for the following purposes:

(Date or Dates)

______________________________________________________________________________

______________________________________________________________________________

My child:         o Shall return to school immediately following the assignment, or

(Check one:)         o Is not required to return to school immediately following the assignment because ________________________________________________________

I understand that in the event an accident occurs, the automobile and/or my insurance company will have primary responsibility.

I agree to permit a student, to ride in my vehicle and/or my child’s vehicle, driven by my child and covered by my insurance and/or my child’s insurance, and I assume primary responsibility for the insurance coverage. I understand that the insurance covering the vehicle will serve to cover my child and the passenger in the event of injury.

I agree to permit the following student(s) to ride in my vehicle and/or my child’s vehicle:

_____________________________________________________________________________

I hereby agree to hold the Montgomery County Schools and the Montgomery County Board of Education and any and all of their agents and employees harmless from any and all liability, damages, expenses, or financial obligations arising out of any school related student trips.

PRINCIPAL/DESIGNEE AUTHORIZATION

Approved By __________________________________________________, Principal/Designee

Driver Approved By __________________________________________________, Sponsor

Passenger Approved By __________________________________________________

____________________________                         ____________________________

Student Signature                                                     Parent/Guardian Signature

**If there is a change in driver, passenger or destination, a new form must be completed.**

 

STUDENTS                                                                                                               09.36 AP.211

                                                                                                                                    (Continued)

School-Related Student Trip Permission Slips and Medical Release Form

Student Passenger

THE STUDENT RIDING AS A PASSENGER IN A VEHICLE DRIVEN BY ANOTHER STUDENT AND THE PARENT/GUARDIAN OF THE STUDENT RIDING AS A PASSENGER IN A VEHICLE DRIVEN BY ANOTHER STUDENT MUST COMPLETE THIS FORM.

Student Passenger: ___________________________________________________________

Purpose: ____________________________________ (i.e., journalism, MSU, yearbook, co-op)

Date(s) of Trip(s) ______________ Departure Time _________ Return Time _________

Destination _________________________________________________________________

Names of Principal-Designated Sponsors ______________________________________

PARENT/GUARDIAN SCHOOL-RELATED TRAVEL PERMISSION

I agree that my child, _____________________________, may leave school in an automobile on _________________, 20____, at ________________ o’clock for the following purposes:

(Date or Dates)

______________________________________________________________________________

______________________________________________________________________________

My child:         o Shall return to school immediately following the assignment, or

(Check one:)     o Is not required to return to school immediately following the assignment because ________________________________________________________

I give permission for my child, ______________________, to ride in a vehicle driven by ____________________. I understand in the event of an accident, the policy covering the vehicle will cover my child.

I hereby agree to hold the Montgomery County Schools and the Montgomery County Board of Education and any and all of their agents and employees harmless from any and all liability, damages, expenses, or financial obligations arising out of any school related student trips.

PRINCIPAL/DESIGNEE AUTHORIZATION

Approved By __________________________________________________, Principal/Designee

Driver Approved By __________________________________________________, Sponsor

Passenger Approved By __________________________________________________

____________________________                         ____________________________

Student Signature                                                     Parent/Guardian Signature

**If there is a change in driver, passenger or destination, a new form must be completed.**

Review/Revised:7/21/11

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