Field Trip/Travel Information, Permission, and Release Form
Please return page 2 and, if needed, page 3 (medication authorization/additional health information).
Trip: Philadelphia Area Ethics Bowl Competitions at Villanova University
Date(s): 12/7/13
Trip leader: Ellen Johnson, 302-540-0960
Other chaperones: parents
Purpose of trip: attend and compete in an interstate competition in Bioethics Bowl
[ ] IF box is checked, your signature on page 2 authorizes the following charge to your student’s account toward the cost of this trip:
Itinerary/student activities with transportation, lodging, and level of supervision (e.g. supervised small groups; periodic check-in; independent activity) for each component of the trip:
(all supervised small group)
7:00 – Vans leave WFS (teachers and parents driving)
7:45/8:00 Arrive and register – Bartley Hall Cafeteria, Villanova University, Villanova PA
9:00-12:00 Early rounds of competition (breaks for snacks, bring your own)
12:00/1:00 – lunch – café available on campus or transport to fast food nearby
1:00-4:00 – Final rounds and finish with announcements
4:30-5:30 return to WFS
Required and recommended items for students to take on the trip:
Materials for note taking (laptops if safely carried – supervision provided)
Snacks for morning break, water bottles
Trip:
Student’s name ______
Medical/emergency contact information (REQUIRED for all trips):
Please provide name and two phone numbers for each parent/guardian):
Parent/Guardian 1 ______contact information:
______
Parent/Guardian 2 ______contact information:
______
Student’s physician’s name and contact information (REQUIRED for overnight trips):
______
If your child will be taking medications during this trip, please complete page 3 of this form, “Medication Authorization and Additional Health Information.”
Release and medical treatment authorization (REQUIRED signature for all trips):
By signing below, I give my child permission to participate in this trip—with the transportation, lodging, and activity arrangements described—and authorize the account charge indicated on page 1 (if applicable).
In the event of an emergency, when a parent/guardian is unavailable, I authorize the faculty and staff trip chaperones to make arrangements, in accordance with their best judgment, for my child to receive medical care. I acknowledge that the costs of such medical care will be my financial responsibility.
I hereby release, hold harmless, and indemnify Wilmington Friends School, its employees, agents, representatives, and all persons acting pursuant to its authority from any and all liability for damages to person and/or property arising in any way from or on account of my child’s participation in this trip.
I further understand, and have discussed with my child, that the rules of conduct set forth in the school Handbooks apply on this trip. Violations of those rules will result in disciplinary action, up to and including expulsion and including the possibility that the child will be sent home from the trip, and that disciplinary consequences may extend beyond the duration of the trip.
______
Signature of parent/guardian Date
Trip: Philadelphia Area Ethics Bowl 12/7/13
Student’s name ______
Medication Authorization and Additional Health Information:
[ ] If box is checked, there will be no nursing coverage on this trip. The nurse provides instruction to faculty or staff members on assisting students with medication.
For emergency, “as needed,” and daily use medications, parents/guardians must provide the appropriate doses for the duration of the trip and must provide all medications, prescription and over-the-counter, in the original, clearly-marked containers. Please give medications to the nurse in advance of the trip. Chaperones must carry all medications (except epi-pens and inhalers that students already have permission to carry themselves).
NOTE:
Beginning Sept. 2013, OTC medications to be taken on a field trip must be accompanied by a doctor’s request.
To authorize faculty or staff chaperones to assist with medication (parent/guardian signature REQUIRED):
The trip chaperones have my permission to assist my child with medication, as indicated.
Name of medication(s): ______
Amount to take: ______
Time to take: ______
How it is taken (route): ______
Reason for taking: ______
I have instructed my child on the proper procedure for taking the medication(s) indicated. I further understand that my signature below fully waives any claim for liability that may exist against any faculty or staff member resulting from the assistance with medication to my child. I understand that I must provide all medications in the original containers to the school nurse prior to the trip.
______
Signature of parent/guardian Date
Please use the space below to provide any additional health information you would like the chaperones and/or the school nurse to be aware of prior to and during this trip.
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