FIELD TRIP PERMISSION SLIP

I GIVE PERMISSION FOR MY SON/DAUGHTER (STUDENT NAME)_____________________
TO ACCOMPANY THE ____________________CLASS ON A FIELD TRIP TO ____________
________________________________ ON ______________________________________.

IN THE EVENT OF A SERIOUS INJURY/ACCIDENT, I GIVE PERMISSION FOR MY CHILD TO BE TAKEN TO THE NEAREST PHYSICIAN OR HOSPITAL AND TREATED.

BELOW PLEASE LIST THE NAMES OF PARENT/GUARDIAN AND/OR PERSONS TO BE
CONTACTED IN THE EVENT OF AN EMERGENCY AND THE TELEPHONE OR BEEPER NUMBERS WHERE THEY CAN BE REACHED ON THE ABOVE DATE!
 
FIRST CONTACT:
(PARENT/GUARDIAN) ________________________________________________________
HOME TELE. #________________________WORK TELE. # __________________________

SECOND CONTACT:__________________________________________________________
TELE. # ____________________________________________________________________

THIRD CONTACT:_____________________________________________________________
TELE. # _____________________________________________________________________

FAMILY PHYSICIAN:____________________________________________________________
TELE. # _____________________________________________________________________

FAMILY DENTIST:______________________________________________________________
TELE. # _____________________________________________________________________
1. IS YOUR CHILD ALLERGIC TO ANY FOOD AND/OR MEDICATION? (YES/NO)____________
LIST:_______________________________________________________________________
___________________________________________________________________________


2. IS YOUR CHILD CURRENTLY ON ANY MEDICATION? (YES/NO)______________________
LIST:_______________________________________________________________________
___________________________________________________________________________



3. IS IT NECESSARY FOR YOUR CHILD TO TAKE MEDICATION ON THIS TRIP? (YES/NO)____
LIST:_______________________________________________________________________
___________________________________________________________________________



4. DOES YOUR CHILD HAVE A SERIOUS HEALTH CONCERN? (YES/NO)_______________
LIST:_______________________________________________________________________
___________________________________________________________________________



SIGNATURE:______________________________________ DATE: ___________________

************* SPECIAL INSTRUCTIONS *************
Price of admission and/or bus_________________________________


Bus will depart at _______________________ and return by ___________________________

Lunch required __________________________  Drink required ________________________

Special clothing required _______________________________________________________

Other ______________________________________________________________________


PLEASE RETURN PERMISSION SLIP TO SCHOOL BY ________________________________
IF YOU ARE A CHAPERONE ON A FIELD TRIP, NO SIBLINGS OR ADDITIONAL CHILDREN ARE PERMITTED.  THANK YOU FOR YOUR COOPERATION.