Everett Public Schools Field Trip
2320P
Informed Consent Notice
Page 22 of 27
Coordinating Staff Member Signature
Date
Building Administrator/Designee Signature
Date
Field Trip Title
Student Name
Destination:
Place of Lodging:
Address:
Phone # :
Trip Purpose/Objectives:
Class/Staff Member:
Departure
Return
Number Attending
Date:
Date:
Students
Adults
Time:
AM/PM
Time:
AM/PM
Itinerary attached:
?
Yes
?
No
Location:
Location:
Item list attached:
?
Yes
?
No
Type of Transportation
?
District Bus
?
District Vehicle
?
Commercial Transportation
?
Other:
?
No District Transportation Provided (parent/guardian arranged transportation)
SECTION TO BE COMPLETED BY PARENT/GUARDIAN
Student ID Number
Student Name
Medical Information
□
My student
does not
have any special health problems.
List any special health problems. The following special health problems should be noted and adequate precautions taken (list such items as
unusually severe reaction to bee stings, other severe allergies, hemophilia, diabetes, heart disease, etc.)
Any medication, prescription or non-prescription, must have signed orders from a licensed health care professional and parent/guardian.
My student
□
is not
taking any medications or topical(s) on this field trip.
My student
□
is
taking the following medication(s) or topical(s) on this field trip.
Name of medication
Name of medication:
Name of Prescribing Health Care Provider:
Phone number:
Medical Release
In the event of an accident or illness, I understand that reasonable effort will be made to contact the student’s parent/guardian immediately.
However, if they are not available, I authorize the school district to secure emergency medical care as needed.
Name of Primary Care Doctor
Phone No.
Primary Care Doctors Clinic
Clinic Phone No.
Name of Insurance Carrier
Policy No.
This activity provides a learning experience for the students and allows them an opportunity to apply their classroom learning. Although I
understand that the school district will make reasonable effort to provide a safe environment, I am fully aware of the special dangers and risks
inherent in participating in the activity. Being fully aware of the risks, I hereby give consent for my student to participate in the activity. My
signature reflects my knowledge of the details of the trip and the itinerary.
Date
Emergency No:
Signature of Parent/Guardian
Parent/Guardian Name
Home Phone No.
Home Address
Work Phone No.
Cell Phone No.
Please return this form to
before (date)
and keep any attachment for your information.