Student Name ________________________ School _________________ Date ___________
GENERAL INFORMATION
The __________________________________ is planning a trip to ____________________
Purpose of trip _____________________________________________________________
Trip Destination ____________________________ Phone No. (_______)_______________
Address _________________________________ Place of Lodging ____________________
We will leave from _____________________________________ at ________ ❑ AM ❑ PM
on(date) __________________ We will return to the school on (day) __________ (date) ________
at ________ ❑ AM ❑ PM ❑ Itinerary is attached ❑ List of items needed is attached
Attending: number of students ________ minimum number of chaperones ________
TYPE OF TRANSPORTATION
❑ District Vehicle ❑ Commercial Transportation ❑ District Bus ❑ Other (explain) ______________
MEDICAL INFORMATION
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.) __________________________________________________________
The following medications, prescriptions or special diets are needed: ________________________
MEDICAL RELEASE
In the event of an accident or illness, I understand that reasonable effort will be made to contact the parent/guardian immediately.
However, if I am not available, I authorize the school district to secure emergency medical care as needed.
Medical insurance? _____ yes _____ no
Name of Preferred Doctor _______________________________ Phone (______)______________
Name of Insurance Carrier _______________________________ Policy No. ___________________
If you have questions or concerns about this activity, please contact _____________________________
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 (student) ________________ to participate in the activity.
Parent/Guardian Name ___________________________ Day Phone (_____)__________________
Home Address _________________________________ Evening Phone (_____)_______________
Emergency Contact______________________________ Emergency Phone (_____)____________

Signature of Parent/Guardian _______________________ Date _________________________
Parent/guardian signature reflects their knowledge and approval of the activity described above. This form must be returned to school before the student is involved in the activity.