Parent/Guardian Permission Form for Field Trip

As parent/guardian of _______________________________, I give permission for

                                                      (Name of Student)

his/her participation in the Ayden-Grifton High School sponsored field trip on

___________________________. The itinerary includes the following information:

                    (Date)

Departure _____________ A.M./P.M.                        Return____________  A.M./P.M.

Destination: __________________________________________________________

Total Cost to Student: __________________________________________________

Place of Lodging (if overnight): __________________________________________

Rules and regulations governing the trip are attached.

In case of emergency please contact:

Parents/Guardian’s Name ____________________Address___________________

Phone Number _____________________ Work Phone ______________________

If parents cannot be reached please contact:

Name _____________________________ Relationship _______________________  

Phone Number _____________________ Work Phone ______________________

Teacher(s)/Chaperones Involved: __________________________________________

Comments:____________________________________________________________  

 Signed: _______________________ (Parent/Guardian)

 Date: _________________________

Medical Authorization Form For Field Trips

 I/we the undersigned parents and/or guardian(s) of ________________________

                                                                                                         (Student’s name)

a minor, do hereby grant permission to the responsible adults supervising on school field trips, to any hospital, to any physician, or any other organization providing medical treatment to ________________________, during said field trip in the event that we are

               (Student’s name)

not readily available to give our permission for such treatment. I/we agree to hold any responsible adult who gives permission harmless and to release that individual from any liability in connection with granting such permission for treatment and, furthermore, we do hereby release, acquit, discharge, and covenant to hold harmless, the Pitt County (N.C.) Board of Education, its agents and employees, from any and all actions, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in any way growing out of the granting of permission for any emergency medical care for my/our child, _________________________, during his/her participation in the                                                 (Student’s name)

above-described trip.

            I/we also specifically inform the Pitt County Schools and the responsible adults participating in the field trip that my/our child, ___________________________, has the

                                                                   (Student’s name)

following special medical needs, including any allergies or other special medical needs:

_______________________________________________________________________________________________________________________________________________.

In connection with these specific needs, we shall furnish to the responsible adults supervising a field trip any necessary information, in writing, from our child’s personal physician regarding any special medical needs or conditions that our child may have together with instruction for appropriately dealing with such needs or conditions.

            I/we acknowledge that I/we have carefully read the foregoing medical authorization and know the contents applies to all field trips taken during the designated school year and that I/we sign this or the same as my/our own free act.

______________________________                        _____________________________

                 Parent/Guardian                                          Student Participant (if over 18)

_________________________________________________________________

(Health Insurance Company and Number)

Date: ________________    Parent/Guardian Signature________________________