FIELD TRIP PERMISSION FORM (Overnight) Important Directions: (1) Use one form per trip, (2) Teacher completes the Field Trip Information section, (3) Duplicate one form per student, and (4) Send a copy home for parent(s) to complete remaining sections (front and back) and sign. STUDENT INFORMATION STUDENT’S LAST NAME STUDENT’S FIRST NAME DATE OF BIRTH (MM/DD/YYYY) MAILING OR STREET ADDRESS/APT # CITY, STATE, AND ZIP CODE SCHOOL NAME HOMEROOM TEACHER/GRADE FIELD TRIP INFORMATION FIELD TRIP DESTINATION DATE(S) OF FIELD TRIP MEANS OF TRANSPORTATION DEPARTURE TIME FROM SCHOOL RETURN TIME TO SCHOOL COST OF TRIP EMERGENCY CONTACTS For precautionary measures, please provide your home phone number OR the phone number where you may be reached on the day of the field trip. In addition, please provide one or two other contacts (a relative, friend, sitter, etc.) and their phone numbers in case of an emergency and we are unable to reach you. NAME OF PARENT/GUARDIAN TO CONTACT PHONE NUMBER OF PARENT CONTACT INDICATE PHONE NUMBER TYPE HOME WORK CELL NAME/RELATIONSHIP ADDITIONAL CONTACT PHONE NUMBER OF CONTACT INDICATE PHONE NUMBER TYPE HOME WORK CELL NAME/RELATIONSHIP ADDITIONAL CONTACT PHONE NUMBER OF CONTACT INDICATE PHONE NUMBER TYPE HOME WORK CELL MEDICAL INFORMATION FIRST AND LAST NAME OF PRIMARY HEALTHCARE PROVIDER FOR STUDENT HEALTH INSURANCE PLAN DATE OF LAST TETANUS POLICY NUMBER HEALTHCARE PROVIDER PHONE NO HEALTH INSURANCE KNOWN ALLERGIES: (List ALL, including medication allergies. If NONE, so indicate.) SPECIAL MEDICAL CONSIDERATIONS/INSTRUCTIONS. If NONE, so indicate. MEDICATIONS: My child takes the following daily and/or emergency medication(s). If NONE, so indicate. I understand that I need to contact the school nurse to complete all necessary medication forms prior to the scheduled field trip. PV SCHOOLS SPONSORED TRAVEL Water facility usage is permissible while traveling if activity is staffed with certified lifeguards. There are inherent risks in using water facilities. If you choose to have your child participate, you accept those risks. STUDENT’S SWIMMING ABILITY STATEMENT – REQUIRED if traveling to a Water Facility Please mark one of the boxes below to indicate that you are aware of your child’s ability to swim or to be near any pool of water. By signing this permission slip, you are stating that you accept the risks involved in using water facilities. MY CHILD HAS THE APPROPRIATE LEVEL OF SWIMMING SKILLS TO SAFELY PARTICIPATE IN ALL WATER PARK ACTIVITIES: YES NO * For all other water-related field trips, see attached form for information regarding the activities involved. PARENT SIGNATURE REQUIRED I allow my above-named student to attend the field trip that has been scheduled. If any illness or injury occurs, I authorize a school representative to obtain emergency treatment for the above student at the closest medical facility unless instructed otherwise by paramedics or according to the special instructions listed above. I understand that the school assumes no responsibility other than the exercise of prudent supervision. All medical expenses will be covered by my own medical carrier. PLEASE CONTACT ME IF A PARENT VOLUNTEER IS NEEDED: YES NO PARENT/GUARDIAN SIGNATURE FOR FIELD TRIP: DATE: PARENT/GUARDIAN SIGNATURE FOR EMERGENCY MEDICAL TREATMENT: DATE: Revised 07.20.15 (ENG) Continued on Reverse Side OVERNIGHT FIELD TRIP OVER-THE-COUNTER MEDICATION RECORD EXCURSIÓN CON ESTADÍA POR LA NOCHE - REGISTRO DE MEDICAMENTOS DE VENTA LIBRE Student Name [Nombre del alumno] Teacher [Maestro] Grade [Grado] In case of minor injury or illness during the overnight field trip, I authorize the accompanying medical personnel or principal designated supervising teacher to be my agent to give my child the age-appropriate dosage as directed on the packaging of over-the-counter medication indicated below. I understand alternate methods of care will be used before medication is given (i.e., eating, hydration, resting, etc.). / En caso de alguna lesión o enfermedad leve durante la excursión con estadía por la noche, autorizo al personal médico acompañante, o maestro supervisor designado por el director, para suministrar a mi hijo la dosis apropiada para su edad, indicada en el envase del medicamento de venta libre mencionado más adelante. Entiendo que se usarán métodos alternos de cuidado, antes de suministrar el medicamento (p. ej: comer, tomar agua, descansar, etc.). I agree to, and do hereby hold the district and its employees harmless from any and all claims, demands, causes of actions, liability, or loss of any sort, because of or arising out of acts or omissions with respect to this medication. / Convengo y por la presente libero de cualquier responsabilidad al distrito escolar y sus empleados por todos y cada uno de los reclamos, demandas, procesos de acción legal, obligaciones o pérdidas de cualquier clase debido a, o como resultado de acciones u omisiones con respecto a este medicamento. PLEASE INITIAL NEXT TO THE MEDICATIONS YOU ARE AUTHORIZING FOR ADMINISTRATION Regardless of a venue medication list (if any), I understand that ONLY the over-the-counter medications listed below will be available. ESCRIBA SUS INICIALES EN EL CUADRO CORRESPONDIENTE A LOS MEDICAMENTOS QUE AUTORICE SE DISPENSEN A SU HIJO Entiendo que SOLAMENTE estarán disponibles los siguientes medicamentos de venta libre, sin tener en cuenta cualquier lista de medicamentos (si la hay) de una sede de excursión. Parent Initials Parent Initials Medication Medication Tylenol® (Acetaminophen), adult 500mg tablet Tylenol® (Acetaminophen), tableta de 500mg-adultos Tums® (Calcium Carbonate), 500mg tablet Tums® (Calcium Carbonate), tableta de 500mg Tylenol® (Acetaminophen), adult 325mg tablet Tylenol® (Acetaminophen), tableta de 325mg-adultos Dramamine® (Dimenhydrinate), 50mg tablet Dramamine® (Dimenhydrinate), tableta de 50mg Tylenol® (Acetaminophen), children's chewable 80mg Tablet Tylenol® (Acetaminophen), tableta de masticar de 80mg-niños Calamine Lotion (applied topically as needed) Loción Calamine (aplicación local según sea necesario) Motrin®/Advil® (Ibuprofen), 200mg tablet Motrin®/Advil® (Ibuprofen), tableta de 200mg Advil® Junior Strength, chewable 100mg tablet (ages 6-11) Advil® Junior Strength, tableta de masticar de 100 mg (para niños de 6 a 11 años) Benadryl® (Diphenhydramine), adults and children age 12 and over, 25mg tablet Benadryl® (Diphenhydramine), tableta de 25mg-adultos y niños de 12 años y mayores Signature of Parent/Guardian [Firma de un padre de familia o tutor legal] Date [Fecha] To Be Completed By Administrator Of Overnight Field Trip Medications Esta sección la llena el encargado de administrar medicamentos durante una excursión con estadía por la noche Medication Record OTC Medication Given Date Time Given By OTC Medication Given Date Medical Professional/Supervising Teacher Signature Revised 07.20.15 (ENG) Time Given By Initials Continued on Reverse Side