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School Field Trip Permission Form
Student Name (Last, First)*
Teacher Name
Parent Contact Info
Parent/Guardian Name (Last, First)*
Street Address
City, State, ZIP Code
Phone*
--
Email
Field Trip Info
Departure Date*
Departure Time
Return Date*
Return Time
Method of Transportation*
Destination*
Street Address
City, State ZIP Code
Activities Planned*
Medical Info
Does student have any medical/health issues of concern?*

Yes No

Does student need to travel with any medication (ex. EpiPen, inhaler)?
In case of emergency, I give permission for the teacher/chaperone to seek medical attention for my child.*
By signing above, I acknowledge that the school district does not provide medical insurance for my child for purposes of this trip. I understand that I am responsible for providing such insurance, and for payment of any medical treatment expense for my child not covered by insurance.
Physician's Name*
Physician's Phone*
--
Alternative Emergency Contact
Name
Relationship
Phone
Signature*
Date Signed*

Name	Relationship	Phone

School Field Trip Permission Form