SHENENDEHOWA                    Field Trip and Emergency Consent Form
      CENTRAL SCHOOLS                                    

I am aware that the __________________________________ will be traveling to _________________________ _________________ on ________________. My child has my permission to travel with this organization.

I, _________________________ (parent/guardian, please print), give permission to Shenendehowa staff or chaperones to act on my behalf for _______________________ (student name, please print), in the event of a medical emergency.
Date of Birth________________________________ Home Phone______________________________________
Father Daytime Number _______________________ Mother Daytime Number_____________________________
Family Physician ____________________________ Phone Number ____________________________________
Family Dentist ______________________________ Phone Number ____________________________________
Insurance Company __________________________ Policy Number ____________________________________
Insurance Address ___________________________ ________________________________________________
Name of Insured _____________________________ Employer ________________________________________
If parent or /guardian can't be reached, please contact:  
Name _____________________________________ Phone Number ____________________________________
Name _____________________________________ Phone Number ____________________________________


I hereby grant permission for Shenendehowa Central School District and its employees full authority to take whatever action they deem necessary regarding my child's health and safety in the event I cannot be reached or in a situation where time is of the essence; and fully release the Shenendehowa Central School District and it's employees from any liability in connection with those decisions. I grant permission for emergency treatment by a rescue squad, private physician and/or hospital or emergency health care facility staff if needed. Any such action will be taken in the best interests of my child and will be reported to me as soon as possible.

Please indicate if your child has: (Check all that apply and describe below)

Asthma ___________ Seizures __________ Last Tetanus (date)_______________ Other _______________
Severe Allergy ______ Diabetes __________ History of Surgery (describe) _______
Other Allergies _____ Special Diet ________ Physical Limitation_______________
 
 
 


Will medication be required during the field trip?    Yes _____    No _____
Describe _______________________________________________________________________
A doctor’s order and written parental permission must be on file in the health office. Self directed students who have permission to self carry may do so with the medication in the original labeled container. If the self directed student does not have permission to self carry, the teacher will need to carry the medication. Non-self directed students will need to have a parent, parent designee (non-school employee) or a nurse accompany them on the trip to administer their medication. 

My signature gives permission for both the field trip and any necessary medical action.

_______________________________      __________________________
Parent Signature                                                                 Date

HRE2 (rev. 8/06)