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 Upcoming
Field Trip Form
Lake
Washington School District # 414
PARENT/GUARDIAN FIELD
TRIP
INFORMED CONSENT FORM
I hereby give my
permission for,
(name of student)
who
attends Thoreau Elementary
(school)
to participate in a field trip to Big Finn Hill
Park
(destination)
on
June 15 for the purpose of forest
study
Transportation
for this activity will be provided by:
x
District
bus/vehicle
Other :walking
******************************************************************************
As parent, or legal guardian, I authorize a
qualified physician to examine the above-named student and in the event of
injury to administer emergency care and to arrange for any consultation by
a specialist, including a surgeon, as deemed necessary to insure proper
care of any injury. I understand that every effort will be made to contact
parent or guardian to explain the nature of the problem prior to any
involved treatment.
In the event it becomes necessary for the Lake
Washington School district staff-in-charge to obtain emergency care for
your student, neither the staff-in-charge nor the Lake Washington School
District assumes financial liability for expenses incurred because of
accident, injury, illness, and/or unforeseen circumstances.
Student address:
Student home phone no. Date
of birth
Describe any medical condition,
including allergies that could impact the student’s field trip
experience: p None p See below
On
the line below, please print parent/guardian name, and home, work and/or
cellular phone number:
In
the event of an emergency (injury, illness, and unforeseen incident) the
following person must be notified in case the parent/guardian cannot be
contacted:
Name:
phone
no.
I have read the attached itinerary and understand
that the school district will make every reasonable effort to provide a
safe environment during the field trip.
As the parent/guardian of the above named student I understand that
there are inherent risks associated with participation in these activities
including physical injury, and/or other consequences. I acknowledge that school rules apply on
all field trips.
I received a detailed itinerary p yes p no
I received a list of things to bring (if any) p yes p no
My child weighs more than 60 pounds p yes p no
Signature
of parent or guardian Date
Lake Washington School District # 414
PARENT/GUARDIAN FIELD
TRIP
INFORMED
CONSENT FORM
I hereby give my
permission for,
(name of student)
who
attends,
(school)
to participate in a field trip to:
(destination)
on
_______________________for the purpose of
(date)
Transportation
for this activity will be provided by:
p
District
bus/vehicle
p Other
*******************************************************************************************
As parent, or legal
guardian, I authorize a qualified physician to examine the above-named
student and in the event of injury to administer emergency care and to
arrange for any consultation by a specialist, including a surgeon, as
deemed necessary to insure proper care of any injury. I understand that
every effort will be made to contact parent or guardian to explain the
nature of the problem prior to any involved treatment.
In the event it becomes necessary for the Lake
Washington School district staff-in-charge to obtain emergency care for
your student, neither the staff-in-charge nor the Lake Washington School
District assumes financial liability for expenses incurred because of
accident, injury, illness, and/or unforeseen circumstances.
Student address:
Student home phone no. Date
of birth
Describe any medical condition,
including allergies that could impact the student’s field trip
experience: p None p See below
On
the line below, please print parent/guardian name, and home, work and/or
cellular phone number:
In
the event of an emergency (injury, illness, and unforeseen incident) the
following person must be notified in case the parent/guardian cannot be
contacted:
Name:
phone
no.
I have read the attached itinerary and understand
that the school district will make every reasonable effort to provide a
safe environment during the field trip.
As the parent/guardian of the above named student I understand that
there are inherent risks associated with participation in these activities
including physical injury, and/or other consequences. I acknowledge that school rules apply on
all field trips.
I received a detailed itinerary p yes p no
I received a list of things to bring (if
any) p yes p no
My child weighs more than 60 pounds p yes p no
Signature
of parent or guardian Date
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