St. Bonaventure Catholic School
1604 15th St.
Columbus, NE 68601
402-564-7153
PARENT/LEGAL GUARDIAN PERMISSION SLIP
FOR FIELD TRIP PARTICIPATION
Dear Parent or Legal Guardian:
Your son/daughter/guardianship is eligible to participate in a school-sponsored activity which requires transportation to a location away from the school site. This activity will take place under the guidance and supervision of employees from St. Bonaventure School. A brief description of the activity follows:
Destination: ______
Designated supervisor of activity: ______
Date and time of departure: ______
Date and anticipated time of return: ______
Method of transportation: ______
Student cost: ______
If you would like your child to participate in this event, please complete, sign and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student.
I hereby consent to participation by my child, ______, in the event
described above. I understand this event will take place away from school grounds and my child will be under the supervision of the designated school employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.
I hereby authorize ______to take my child for medical treatment
Teacher
in the event of an emergency in which neither parent can be reached. (Parents will be notified immediately in case of an emergency.) I authorize any licensed physician or medical center to treat my child.
______
______
Parent’s Name/Signature
______
Emergency Phone Number Address
St. Bonaventure Catholic School
1604 15th St.
Columbus, NE 68601
402-564-7153
Health Form and Medical Release
Name ______Date of Birth ______Age _____Sex___
Parent/Guardian ______Home phone______
Work phone ______
In emergency, notify ______
(Other than parent or guardian)
Address ______Phone ______
Past illness of importance:
Penicillin or other drug reactions and/or allergies:
Is the child under any special medical treatment or diet that needs to be continued?
______
Health Insurance information:
Name of insured: ______Insurance Company______
Insurance policy # ______Insurance certificate ______
Signature: ______Date: ______