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Field Trip Permission & Medical Release Form

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I am the Parent or Legal Guardian of the student named and give permission to participate in this field trip.

My Child ________ has my permission to attend the following Field Trip.

Answer required for "My Child ________ has my permission to attend the following Field Trip."

Field Trip:

Answer required for "Field Trip: "

Location: [ location of the field trip]; Date: [date and time the field trip is taking place]; Cost:[ total student cost of the field trip]

Answer required for "Location: [ location of the field trip]; Date: [date and time the field trip is taking place]; Cost:[ total student cost of the field trip]"

Parent/Guardian Name*

Answer required for "Parent/Guardian Name"

Parent/Guardian Signature*

Signature Required

Below, please list your child's medical conditions/concerns (ex. allergies, asthma, diabetes, and seizures), and medications that the Centralia School District Offical(s) should be aware of:

Answer required for "Below, please list your child's medical conditions/concerns (ex. allergies, asthma, diabetes, and seizures), and medications that the Centralia School District Offical(s) should be aware of:"

Below, please list any *medication* your child needs to take with them on the Field Trip:

Answer required for "Below, please list any *medication* your child needs to take with them on the Field Trip:"

* An "Administration of Medication at School" form must be completed for each medication (for either prescription or over the counter) if it is not already routinely being given at school. The medication must be in its original container or labeled prescription bottle. Both the form(s) and medication(s) must be delivered to the health room by the student's parent/guardian during the week before the field trip.

I give my permission for my son/daughter to receive treatment of an injury in case of an emergency by any physician or hospital designated by a school official(s), except as may be noted below.

Answer required for "I give my permission for my son/daughter to receive treatment of an injury in case of an emergency by any physician or hospital designated by a school official(s), except as may be noted below."

For overnight field trips, please upload front and back picutres of your child's medical insurance card.

Answer required for "For overnight field trips, please upload front and back picutres of your child's medical insurance card."

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Emergency Contact Information

First and Last Name

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Relationship

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Mobile/Home Phone

Number Required

Work Phone

Number Required

This information will be helpful in determining your child's particular needs in order to keep him safe during this field trip. It is confidential- shared only on a "need to know" basis with school officials who are participating with your child.

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"