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

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

 

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:  

 

 

FOR OVERNIGHT TRIPS:

ALL PARENT/OTHER CHAPERONES HAVE ATTENDED VOLUNTEER TRAINING

DATE/TIME OF PRE-TRIP CHAPERONE MEETING:

FOR OUT OF COUNTRY TRIPS:  TRAVEL AND CANCELLATION INSURANCE ARRANGEMENTS (ATTACH COPY OF CONTRACT WITH INSURANCE AND CANCELLATION PROVISIONS HIGHLIGHTED).

APPROVAL OF TRAVEL:

Principal or AD: _______________________________________DATE: ______________

Superintendent: _______________________________________DATE: ______________

School Board: _______________________________________DATE: ______________

 

Cross Reference: 

Form Revised: 

  • January 11, 2022
  • March 10, 2015
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