FINE ARTS FIELD TRIP CONSENT/MEDICAL
RELEASE FORM
Your
child, as a member of the school group listed below, may be required to miss
class(es) to attend activities or events required by the student’s participation
in this group. A calendar of the year’s activities will be sent home with each
student.
PRE-FILED PARENTAL/GUARDIAN
PERMISSION
I
agree that ___________________________________, as a member of
_______________________________, may
(student name)
(name of group)
miss
class(es) during the year to attend activities or events required by the
student’s participation in this group.
______________________________________
______________________
Parent of Guardian (Print Name)
(Date)
Students will be transported to and from the location of
the activities/events by school bus. NOTE: High school students may travel by
private automobile to some events. A special permission for, also requiring your
signature, must be on file before a student may travel in a private
automobile.
MEDICAL INFORMATION
Every effort will be made to see that your child is well
taken care of; however, since we must be prepared for any situation, please
complete the following:
Allergies:______________________________________________________________________
Any
medical history we should
know:_______________________________________________
______________________________________________________________________________
Do
we have your permission to take your child to the nearest doctor or hospital
should in our opinion the situation warrant this action? ______YES
_____NO
The
doctor on call, or doctor contacted, has full permission to treat or render
emergency care:_____YES
_____NO
Family Doctor: _____________________________ ____________________ _______________
(print name)
(phone) (alternate
phone)
Please print names and phone numbers of nearest
responsible parties:
1.
______________________________________________ Phone
_____________________
2.
______________________________________________ Phone
_____________________
I
UNDERSTAND THAT ALL STUDENTS ARE GOVERNED BY THE SAME RULES ON THIS TRIP AS AT
SCHOOL. I ALSO UNDERSTAND THAT ANY INFRACTION MAY RESULT IN DISCIPLINARY
ACTION.
____________________________
_____________________________
____________________
Student name (printed) Student
signature
Date
I hereby
release the Pasadena Independent School District, _____________________School,
and all adult leaders from any liability and from any and all claims against
them individually or collectively, for any injuries which might be received
during this trip or activity, or in traveling to or from the trip’s
destination.
_________________________________ ______________________
___________________
Signature of Parent/Guardian Phone
Date
THIS FORM MUST BE FILLED OUT AND
SIGNED BEFORE THE STUDENT WILL BE ALLOWED TO ATTEND ANY OFF-CAMPUS ACTIVITIES
WITH THE GROUP