IJOA-E2 - PARENT/GUARDIAN CONSENT FORM for STUDENT TRAVEL/FIELD TRIP(draft af_6-28-22)

Group or Team:		# Students attending:


Faculty Leader Name(s):	# of Chaperones: (including Ldr)

Trip Destination:
Trip Date(s):
Anticipated Departure Time:			Anticipated Return Time:

Transportation by:
Driver(s) (if other than school /commercial carrier):

In An Emergency, How Can Trip Leader(s) Be Contacted:

For Overnight Trips:

Accommodations: Physical address, phone
Provisions for Mixed Gender Supervision:

Pre-Trip Parent Meeting (for Trip involving Three (3) or More Overnights) will be:

Date:

Location:

Time:

PARENT/GUARDIAN/STUDENT CONSENT

I hereby give my permission for ____________________(student’s name) to participate in the travel/field trip(s) named and described herewith. I acknowledge receipt of the Field Trip Information form for that trip(s). I am comfortable with the arrangements described. I authorize the trip leader(s) to arrange medical treatment in an emergency. I hereby release the trip leader, the field trip(s) chaperones, the school, and the school department (“School”), town of Cape Elizabeth (“Town”), and all of their agents or employees, from any and all claims, liabilities and responsibilities for damages or injuries that my student may experience during this trip, except only any claims for any damages or injuries that may be sustained as a result of any intentionally harmful acts on the part of the trip leader, the chaperone(s), the Town, the School, or their agents or employees. I understand that it is my responsibility to obtain health insurance coverage for medical expenses that may occur.


Parent/Guardian Signature		Date


Student Signature (if 18 or older)		Date

EMERGENCY CONTACT AND MEDICAL INFORMATION FORM


Student Name		Date of Birth

Health Insurance Provider:

Plan/Certificate #:

1st Contact:
Relationship:
Home/Cell Phone:
Work Phone:

2nd Contact:
Relationship:
Home/Cell Phone:
Work Phone:

Non-Parent/Guardian Contact:
Relationship:
Home/Cell Phone:
Work Phone:

Known Allergies? If yes, provide treatment protocols below:

Medication or Treatment Restrictions:

Medication(s) that student will be bringing for self-administration:

Cross Reference:

Form Revised:

January 11, 2022
March 10, 2015