Out-Of-State School-Related Student Trip Permission Slip/Medical Release Form

STUDENTS 09.36 AP.21 Out-of-State School-Related Student Trip Permission Slip/Medical Release Form

This form to be used for all school sponsored events outside the state of Kentucky This consent form is to be signed only after understanding and agreeing to the information below. If this completed form is not at school by the appropriate deadline and any necessary medications/supplies are not at the school prior to the trip, the student will not be permitted to participate. Deadline to return form to school: ______

Student’s Name ______Last Name First Name Middle Initial

School ______Grade ______Homeroom/Classroom ______

Field Trip Date(s) ______Destination ______

Alternate Destination, if applicable ______

Mode of Transportation ______Cost to Student, if applicable $_____

EXPECTATIONS AND INSTRUCTIONS: I understand the following is expected of the student:  To follow instructions given by a teacher/chaperone.  Not to leave or separate from the group without appropriate authorization from a teacher/chaperone.  Comply with all school and District policies and rules of conduct. In the event any of the above expectations or instructions are violated, I understand school officials reserve the right to remove the student from the trip and the student will be subject to disciplinary consequences. I UNDERSTAND THAT PARTICIPATION IN OUT-OF-STATE TRIPS MAY INCLUDE ACTIVITIES THAT INVOLVE RISK OF HARM TO MY CHILD. I ACKNOWLEDGE I AM FULLY INFORMED OF THE ACTIVITIES CONTEMPLATED. I hereby give permission for my child to participate in the above mentioned school-related student trip(s). I hereby authorize a trained Bullitt County Public School (“BCPS”) official to assist my child in the self- administration of the medications that I have listed on page 2 in non-emergency situations. During an emergency, I authorize any and all physicians, trained school personnel, and/or other medical providers to render such emergency treatment and to release the health information on page 2 as deemed necessary for the health of my child. If any emergency medical procedures or treatments are required during this trip, I consent for the trip supervisor to arrange for them at the supervisor’s discretion. If nursing assistance is needed for a medical treatment or procedure, I consent for the trip supervisor or health coordinator to arrange for them at their discretion.

______Parent/Guardian Signature Date

of 2 STUDENTS 09.36 AP.21 (CONTINUED) Medical Information and Parent/Legal Guardian Medical Authorization Student medication may not be repackaged for field trips by school personnel. If your child needs medication during the school day we are requiring a separate bottle that is obtained from the pharmacy with a correct label and filled with the amount of medication needed for the trip. Please answer all questions and print clearly. 1. List any SEVERE allergies (bee stings, foods, etc.):______2. List any medication allergies: ______3. Please check below IF your child has:  Asthma  Diabetes Kidney Injuries Seizure Disorder Heart Condition  Other Medical Condition Explain:______4. List any medications, including over-the-counter, that your child will need during the field trip. All medications must be in the original containers and only in the amount needed for the field trip. If your child is able to self-administrate, a trained BCPS employee will assist your child in the self- administration of these medications. A completed Medication Permission Form (09.2241 AP.21) must be submitted for each medication. MEDICATION DOSAGE TIME(S) ______5. Is your child physically and mentally capable of self-administering his/her medication in a non- emergency situation?  Yes  No. If No, please explain the circumstances that prevent him/her from doing so. ______6. Name of Insurance Company: ______Policy #:______Child’s full name (print) ______

______Parent/legal guardian name (print) Date

______Parent/legal guardian name (signature) Date

Emergency Contact Telephone Numbers: Home______Cell______Work______Please return these forms to your child’s teacher.