EDUCATIONAL EXCURSION PERMISSION FORM
(IN-COUNTY / OUT-OF-COUNTY TRIPS)
DATE: _______/_______/_________
Dear Parent/s or Guardian:
On ______/______/________ our class will be taking a field trip to _________________________________________. We plan to leave school at approximately ________________ and return to school at approximately ______________. We would like your child to accompany us on this
trip. Please sign the permission slip below and return it no later than ______/______/________.
Lunch: will be provided. will not be provided.
Chaperones: are needed. are not needed.
___________________________________
Teacher Signature
PLEASE SIGN AND RETURN THE PERMISSION FORM BELOW
EDUCATIONAL EXCURSION HOME PERMISSION FORM
Dear ________________________ (Teacher’s Name),
___________________________________________ (Child’s Name) has my permission to go to ___________________________________ with his/her class on _______________. I understand that all reasonable precautions have been and will be taken for the safety of my child. I further agree to hold harmless Hickory Public Schools, its agents, servants, and employees against any and all liability, loss, damages, costs or expenses which the above named child or I may sustain or incur as a result of any act or inaction of any agents, servants, or employees of the Hickory Public Schools School Board.
_______________________________________
Parent or Guardian Signature
CHECK ONE:
__I would like for the school to provide my child with a bag lunch at the cost of his regular daily lunch.
__I choose to provide a bag lunch for my child.
EXTENDED/OVERNIGHT EXCURSION PERMISSION FORM
DATE: _______/_______/_________
Dear Parent/s or Guardian:
On ______/______/________ our class will be taking a field trip to______________________________________________________. We plan to leave on ______/______/________ and return on ______/______/________. We would like your child to experience this learning opportunity.
Please sign the permission form attached no later than _______/________/__________.
A trip itinerary is included.
PLEASE SIGN AND RETURN THE PERMISSION FORM BELOW
EXTENDED/OVERNIGHT EXCURSION HOME PERMISSION FORM
Dear _______________________ (Teacher’s Name):
_____________________________________________________ (Student’s Name) has my
permission to go to______________________________________________________ with
his/her class on _______/________/__________. I understand that all reasonable precautions have been and will be taken for the safety of my child. I further agree to hold harmless the Hickory Public Schools, its agents, servants, and employees against any and all liability, loss, damages, costs, or expenses which the above-named child or I may sustain or incur as a result of any act or inaction of any agents, servants, or employees of the Hickory Public Schools’ School Board.
_______________________________________
Parent or Guardian Signature
Overnight Excursion Procedures
I. Important documents that must be completed by the school and submitted to Central Office before participating in an overnight excursion:
Request(s) for overnight excursions will be forwarded to the Assistant Superintendent of Curriculum and Instruction. Overnight field trips must be approved by the Assistant Superintendent of Curriculum and Instruction at least four (4) weeks prior to the date of the field trip. The following information
needs to be forwarded to the Assistant Superintendent of Curriculum and Instruction:
. Educational Excursion and Bus Authorization Form
. Alabama Course of Study Standards covered by trip
. Itinerary for the entire trip
. Emergency contact numbers (teacher/administrator cell phone numbers)
Note: Educational trips must require transportation by bus only. The Hickory Public Schools System does not have insurance for vehicles that are not system owned; therefore, the use of private vehicles is PROHIBITED. Activity buses have been purchased by the MCPSS to transport small groups of children to special events and contests. Schools can contact the Office of Transportation
for an activity bus driver. The cost per mile will be determined by the State Department of Education Pupil Transportation Division.
II. Important documents that must be completed by the school and parents before students can participate in an overnight excursion:
. Permission Slip for Extended/Overnight Excursion
. Emergency and Health Information Form or copy of Student Health Card
III. Other vital information the school must have on file for overnight excursions:
. A copy of the letter or contract from the bus company transporting the students or chaperones to and from the trip destination (letter must include cost of trip and terms of agreement)
. A copy of the letter from the organization hosting the event outlining the terms and costs of trip for each student and chaperone
. A copy of the letter from the vendor estimating the cost of meals, if meals are not included in trip package
. Copies of the signed Permission Forms for Extended/Overnight Excursion
. Copies of the completed Emergency and Health Information Forms or copies of Student Health Cards
Principals’ Responsibilities:
The principal is responsible for the approval of field trips, including transportation arrangements and supervisory personnel involved in educational excursions. The principal also is responsible for ensuring to the degree possible the safety and well being of students; therefore, all students are expected to be full participants in all educational excursions. This includes utilizing transportation provided/approved by the school, the supervision by teachers and approved chaperones, and visits to only those places identified on
the permission form. Any deviation from this procedure will require prior notification/approval from the principal.
EMERGENCY AND HEALTH INFORMATION FORM
Student’s Name: Telephone #:
|
Date of Birth: Home Address:
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Father’s Name: Contact Phone #:
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Mother’s Name: Contact Phone #:
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Legal Guardian’s Name: Contact Phone #:
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Name of contact in case of emergency, if parent cannot be reached:
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Emergency Contact Address:
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Emergency Contact Phone #:
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Family Doctor:
|
Address: Telephone #:
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Health Insurance: Company:
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Policy # : Telephone #:
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Unusual Health Conditions? __YES __NO If yes, complete the following:
__Diabetes __Heart __Convulsive __Other ____________________________
Condition Seizures
Allergies __YES __NO If yes, name ___________________________________
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Any other health related issues:
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If emergency treatment is required and parent cannot be reached, what does the parent want the school to do? (Please indicate by circling either YES or NO)
1. Contact closest medical facility? YES NO
2. Contact a physician from local referral agency? YES NO
3. Take child to nearest hospital? YES NO
4. Other Suggestions:
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I hereby authorize emergency medical treatment for my child ___________________
Child’s Name
Signature of Parent or Legal Guardian: _______________________________________
Date: ___/___/_____
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NOTIFICATION OF NON-SCHOOL SPONSORED EXCURSION FORM
MEMO TO: Parents and/or Legal Guardian of: ___________________________________
FROM: ______________________________
RE: Field Trip to: _____________________________________________________
DATE: ________/ __________/ __________
This is to remind you that the field trip to ___________________________________ which is being planned for _______/________/________ is NOT sponsored by the Hickory Public Schools’ Board. This letter is sent to make certain that as parents or guardians of a child who will be participating in the excursion you clearly understand the trip is not in any manner sponsored or endorsed by the Hickory Public Schools System. Neither the School Board nor any of its
employees take responsibility for the trip. Should you have any questions regarding this information, please contact me immediately.
PLEASE COMPLETE AND RETURN THE FORM BELOW
HOME ACKNOWLEDGEMNT OF NON-SCHOOL SPONSORED EXCURSION
This is to verify that I have been advised by ______________________________________ that the trip to __________________________________ which has been planned for
_____/______/_______ is not in any manner sponsored or endorsed by <st1:place w:st="on"><st1:PlaceName w:st="on">Hickory <st1:PlaceType w:st="on">Public Schools, nor any agent, servant, or employee of Hickory Public Schools acting in that capacity. I understand that neither the School Board nor any of its agents, servants, or employees assumes any responsibility for the trip.
Parent or Legal Guardian Signature:
________________________________________________
Parent or Legal Guardian Name (Please Print):
________________________________________
Address: ______________________________________________________________________
Participating Student Name (Please Print):
___________________________________________
EDUCATIONAL EXCURSION VOLUNTEER AUTHORIZATION FORM
This is to verify that I ________________________________ hereby authorize each
Principal/School Administrator
of the persons listed below to act on behalf of _________________________School
as a volunteer to chaperone students who will be traveling on ___/___/_____ to
Date
_______________________________________________________. The purpose of this
Destination
trip is ______________________________________________________________________.
The students will depart at approximately _______ and will return at approximately ____________.
The students will be traveling by ________________________________________.
Mode of Transportation
List below are the names, addresses, and phone numbers of the adults authorized to act on behalf of the school system in chaperoning students for the above-referenced excursion:
Done this the _______day of ______________________ 20_____.
____________________________________ ______________________________
Principal Signature Date
___________________________________ ______________________________
Witness Signature Date