Field Trip Permission Form printable pdf download

6153 EXHIBIT A

Bristol Public Schools

Field Trip Permission Form

A parent signature is required on this form for all field trips.

I have read the attached description of the field trip to be held on _________________________

to __________________________________________and hereby consent to the participation of

my child, ____________________________________, in the activities described and I

acknowledge that the Bristol Board of Education, its employees, agents and contractors are not

liable for any injury, including, but not limited to death and serious bodily injury, that may result

from any inherent risk in my child’s participation in this field trip or from the negligent actions

of third parties.

I authorize school officials to send my child home, at my expense, from any field trip should

his/her behavior warrant such action.

I also consent to any emergency medical treatment that my child may require during the course

of this trip. Specifically, I give permission for any EMT or emergency room personnel

providing medical treatment to my child to release any protected health information regarding

my child to accompanying school staff in accordance with the provisions of the Health Insurance

Portability and Accountability Act (“HIPPA”). In signing this authorization, I understand that I

am allowing school personnel to be present in my absence during any emergency interventions

involving my child and consent to the on-site exchange of medical information necessary for

immediate medical treatment. Any protected health information released to school staff during

an emergency shall be treated as confidential student information protected from further

disclosure in accordance with the provisions of Connecticut law and the Family Educational

Rights and Privacy Act (“FERPA”).

I understand that, because travel plans must be determined well in advance of departure, any

prepayments toward this trip may be nonrefundable.

I understand further that Homeland Security issues may force the cancellation of this trip and

forfeiture of my payment. By signing below, I understand and accept that circumstance may

arise between now and departure which could cause the trip to be cancelled, which may result in

financial loss. I further understand that the Bristol Board of Education will not be liable for any

financial losses I may incur should this trip be cancelled due to security or other unforeseen

reasons.

_________________________

__________________________________________

Date

Signature of Parent/Guardian

_________________________

__________________________________________

Physician’s Name

Phone #1

Phone #2

Field Trip Permission Form