Field Trip Consent Form - Pleasant Valley High School Bands

PLEASANT VALLEY SCHOOL DISTRICT
Brodheadsville, PA
2011 - 2012
SECONDARY (Grades 8-12) FIELD TRIP CONSENT FORM
Directions to Parents: Please complete this form and return it to your child's teacher. It will be filed in our
school office. Thank you.
I hereby give permission for my child,____________________________________. To participate in the
Child’s name
_________________________ field trip scheduled for ________________
Destination
Date(s)
I hereby give my permission for my son/daughter to be given emergency medical aid, if necessary.
YES NO.
________________________________
Signature of Parent/Guardian
For parents/guardians of students who need medication:
(Current Medication Authorization form is on file in the nurse's office)
My son/daughter requires the administration of the following emergency medication:
Medication :______________________(inhalers, epipens, anakits, etc.)
Check appropriate box:
My son/daughter may self-administer this emergency medication.
I am willing to accompany my son/daughter on the field trip to administer this emergency
medication.
My son/daughter requires the administration of the following routine medications:
__________________________________________________________
__________________________________________________________
My son/daughter will NOT receive his/her routine medication while on the field trip.
I am willing or would allow _______________________ to accompany my son/daughter
on the field trip to administer this routine medication.
Date:_____________________
_______________________________
Signature of Parent/Guardian
Emergency Contacts
Home Telephone #:________________________ Teacher's Name:_________________________
__________________________ __________________ _____________________
Name Telephone Relationship
__________________________ __________________ _____________________
Name Telephone Relationship
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The Pleasant Valley School District carries liability insurance only and is responsible only when negligence is proven. Normal
childhood accidents are not covered under district policies and remain the responsibility of the parent.
Insurance Information:
Carrier: ____________________________________Policy #________________________

Students (grades K-12) requiring administration of emergency medications on a field trip will
be allowed to carry and self administer the medication if the following criteria have been met:
1) The parent/guardian has completed the section of the field trip consent form that
addresses the administration of emergency medications.
2) The student has on file in the nurse’s office authorization for administration of the
medication that meets all the criteria addressed in Part B of the USE OF
MEDICATIONS – refer to opening day packet.
3) The medication is currently located in a secure place within the school for use by
the student.
4) The student will be responsible, on the day of the field trip, to obtain his/her
medication from the school location to carry on the field trip. The nurse is
responsible for verifying that the medication is properly labeled, verifying the
student is able to state when the medication is to be taken and notifying the teacher
that the student is carrying the medication.
5) The student is to return the medication to the nurse upon returning to the school
unless they have brought medication from home for the field trip. If the student
has brought the medication from home the student must still report to the
nurse on the day of the trip (if the trip is within school hours) to verify the
correct medication has been sent and review information covered in step 4
with the student.
Parents of students (grades K-7) who receive routine medication during school hours
• may choose to have the child not receive his/her medication on the day of the
field trip;
• may choose to accompany the student on the field trip and the parent may
administer the medication; OR
• the parent may make arrangements for another adult to accompany the
student on the field trip to administer the medication.