FIELD TRIP PERMISSION FORM (Overnight)

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 