Parental Consent And Student Medical Information For School Trips printable pdf download

PARENTAL CONSENT AND STUDENT MEDICAL INFORMATION

FOR SCHOOL TRIPS

BY SIGNING THIS CONSENT FORM, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE INFORMATION

BELOW AND THAT ANY INFORMATION I HAVE PROVIDED IS ACCURATE AND COMPLETE TO THE BEST OF MY

KNOWLEDGE. IF THIS FORM IS NOT COMPLETED AND RETURNED BY _______________________, THE

STUDENT WILL NOT BE PERMITTED TO PARTICIPATE AND WILL REMAIN AT SCHOOL IN A SUPERVISED

ACTIVITY.

Trip or Activity Planned

__________________________________________________________________

Attached is an itinerary that includes the place or places to be visited, a daily schedule of activities, and the dates, times, and

places of departure and return.

Date(s) of Trip

____________________________ Purpose of Trip or Activity

__________________________

School ___________________________________ Name of Teacher/Sponsor

__________________________

Method of Transportation

WCPSS vehicle

charter bus/contract vehicle

*privately-owned vehicle

* When privately-owned vehicles are used for transporting students, only the vehicle owner’s liability coverage is applicable to

any vehicular accident. When students are transported by vehicles owned by Wake County Public School System, the school

system vehicle liability coverage is applicable to any vehicular accident.

Changes/Cancellations

I understand school trips may be cancelled when necessary by the principal, superintendent, or board of education. The school

system cannot guarantee reimbursement when such cancellations occur. Parents/guardians will be notified of any significant

change in plans prior to the school trip.

Expectations and Instructions

I understand the following is expected of the student:



To follow instructions given by the teachers/chaperones.



Not to leave or separate from the group without appropriate authorization from a teacher/chaperone.



Comply with all school and district policies and rules of conduct.

In the event any of the above expectations or instructions are violated, I understand school officials reserve the right to remove the

student from the trip and the student will be subject to school disciplinary consequences.

Insurance Coverage

I represent that the student has insurance either through the school system’s student insurance program or through my own

insurance carrier.

I request that ________________________________________________________ (student) be allowed to participate in the trip

and/or activity planned and, recognizing the risks inherent in the trip and/or activity planned, specifically consent to the student’s

participation. In the event of an accident or a medical emergency, I authorize school officials to seek and consent to emergency

medical assistance on the student’s behalf. I will assume responsibility for all expenses. I understand that school officials will use

the contact information provided below to attempt to contact me in the event of such accident or emergency.

Parent/Guardian Signature______________________________________________Date_________________________

This form must be kept with school officials at all times during the school trip.

Page 1 of 2

1713-a

Revised 8/24/15

Parental Consent And Student Medical Information For School Trips

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