Gulliver schools overnight field trip permission form

Trip title/destination/group: ____________________________________________________________________________________
will remain at the school during the trip)

I give permission for my son or daughter to participate in a field trip with the Gulliver sponsor or
teacher named below. Good behavior is expected; any misbehavior may result in the child being sent
home at the parents’ expense.

STUDENT’S NAME: _______________________________________________________________ GRADE: __________________

PARENT OR GUARDIAN SIGNATURE: _____________________________________________ DATE: __________________
(will be taken on the trip)
STUDENT’S NAME: ______________________________ GRADE: _______ HOME PHONE #: _____________________________ BIRTH DATE: ___________________________ SOCIAL SECURITY # (for emergency use only) _____________________________ MOTHER’S NAME: _______________________________________________ CELL PHONE #:______________________________ FATHER’S NAME: _______________________________________________ CELL PHONE #: ______________________________ *Different contacts and phone numbers from above
EMERGENCY CONTACT #1 NAME: ___________________________________ PHONE #: ________________________________ EMERGENCY CONTACT #2 NAME: ___________________________________ PHONE #: ________________________________ FAMILY DOCTOR: __________________________________________________ PHONE #: ________________________________ LIST ANY MEDICAL CONDITIONS, ALLERGIES, OR MEDICATIONS TAKEN AT HOME AND/OR AT SCHOOL: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ FAMILY MEDICAL INSURANCE COMPANY: ___________________________ PLAN #: __________________________________ MEDICAL TREATMENT PERMISSION – SIGNATURE REQUIRED
I understand that in the event that emergency medical treatment is needed that would reasonably require the assessment or
attention by a physician or medical provider, reasonable attempts will be made to reach the parents, doctor, and emergency
contacts. If the aforementioned people cannot be reached, I authorize the Gulliver sponsor, Gulliver teacher, or Gulliver
approved chaperone, or an emergency medical services representative, to take my child to the nearest appropriate treatment
center for medical treatment. I also authorize the administration of first aid treatment for my child.
A school representative may also dispense prescription medication and non-prescribed medications per the authorized
medication form which I understand must be on file with the school prior to the trip. A form is available in the first aid
station if it is not already on file with the school. In addition, in the event of minor injuries or ailments not reasonably
assessed by school personnel or chaperones to require treatment by a medical provider, I authorize the administration of
non-prescribed medications (Tylenol, Advil, Tums, Pepto-Bismol, Imodium, etc.) and understand that Gulliver will make
every reasonable attempt to contact me prior to dispensing medications. I release and hold harmless Gulliver Schools and
School Management Systems for dispensing of any medication.

PARENT OR GUARDIAN SIGNATURE: __________________________________ DATE: ____________________

Parents, please complete this section if your child will not be participating on this trip MY CHILD WILL NOT BE PARTICIPATING ON THIS FIELD TRIP FOR THE FOLLOWING REASON(S) :

Risk Management Supervisor September 09, 2013



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