The Moxie Way

Offsite field trip permission form

/ FIELD TRIP PERMISSION SLIP / EMERGENCY FORM

Please complete this form that will accompany your child on the field trip. This information is necessary should we need to contact you while we are away from the facility. No child will be allowed to participate without this form being completed and signed by the parent or guardian. The information on this form is considered confidential and will accompany the trip leader/nurse on the trip.

Permission is granted for:

to take a trip to the [DESTINATION] by [MODE OF TRANSPORTATION] on [MONTH] [DATE], [YEAR]. Time of departure is [DEPARTURE TIME] and time of return is [RETURN TIME].

PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name:

New Field:

Phone Number

Emergency Phone #:

Please provide the information requested below, as it may be needed in case of an emergency. This information does not modify the information on the emergency card.

Student's Date of Birth

Allergies:

Field label

Conditions requiring special consideration (medical/physical):

Does your student require:

Epipen

Inhaler

ANY MEDICATION CURRENTLY TAKEN

which?

Free Text

(Type of medication and time of administration):

Please be sure to speak to 's Nurse before (enter date below) regarding any medications or special needs your student may have. THIS INFORMATION WILL REMAIN CONFIDENTIAL IT WILL STAY WITH THE SCHOOL TRIP LEADER/NURSE ON THE DAY OF THE TRIP CONTACT INFORMATION FOR DAY OF FIELD TRIP ONLY.

Primary contact name

Relationship

Phone number

CellPhone

Secondary Contact name

Relationship

Phone Number

Cell Phone

Student Physician

Phone

Student Dentist

Phone Number

Free Text

TO ANY DOCTOR OR HOSPITAL: I hereby authorize the release of my child's pertinent medical information to the appropriate professional staff. I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anesthesia, or surgery for my child, as named above, in case of emergency The signature below constitutes authorization to perform any necessary treatment for my child during this field trip

HEALTH INSURANCE INFORMATION:

Company's Name

policy #

Group #

Parent/Guardian Name:

Date:

Print Name

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