TRIP DURATION
PURPOSE FOR TRIP
DESCRIPTION OF SUPERVISION +
Number of: Days Nights
DRIVER
METHODS OF TRAVEL (check all that apply)
DESTINATION
TRIP DESTINATION
NAME OF STUDENT (last, first, middle initial)
STUDENT SWIMMING SKILL LEVEL (if applicable)
LODGING (if applicable)
DEPARTURE TIME COST PER STUDENT *
APPROXIMATE RETURN TIME
DATE OF DEPARTURE
TELEPHONE NUMBER
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
Field Trip Permission/Release
Elementary School Middle School
High School
GRADE
NAME OF SCHOOL
TEACHER
Permission is requested for your child (student) to go on a field trip. To give permission for your child to attend this field trip complete the information in
Section II. Return the completed Field Trip Permission to the teacher named below along with payment* if there is a charge. If this Field Trip Permission is
not returned, your child will not be permitted to attend. This form must be signed by the parent(s) and student, if over 18 years of age. Both parents should
sign if feasible.
SCHOOL CONTACT
A.M. P.M.
A.M. P.M.
Overnight trip **
DATE OF RETURN
In-county
out-of-county
School Bus Walking
Other (specify)
Private vehicle***
Adult Student
Describe the circumstances or times that the students will NOT be supervised by school staff or parents although adult supervisors will be present.
Parents are encouraged to ask any questions about supervision on trip.
Each person transporting the students in a private vehicle must show proof of current automobile liability insurance to the school supervisor and to the
parents/ guardians of the student traveling in the vehicle upon request. Volunteer drivers are required to carry minimum insurance requirements as
specified by FL Statute 627.736 and complete the School Volunteer Application (PBSD 0887).
No penalty of any type will be imposed against the student based upon a failure to pay for the field trip. No student shall be denied the right to
participate for failure to pay for the field trip. The principal may forgo a planned activity or use of a particular item based upon the collection of
insufficient funds to cover the cost of the item or activity. This request is for a voluntary payment.
**
***
Non-swimmer
I agree and my child agrees to abide by all rules and safety precautions relating to this field trip activity. I am aware that during this trip certain risks are
inherent. I understand that this field trip activity may involve certain conditions, hazards and potential dangers, including those associated with traveling in
the above chosen method of travel or those associated with the facilities or property where the field trip will occur or whether the dangers are open and
obvious or concealed. Any questions which have occurred to me have been answered to my satisfaction. I am participating in these activities of my own
free choice. My signature acknowledges that I have been informed of the reasonably expected hazards associated with the field trip in which my child will
be participating. The School District recognizes its responsibility for its negligent acts subject to the limits of Section 768.28, Florida Statutes. Based on
current Florida Law, the School Board is not responsible for the negligence of volunteer drivers. I further agree to accept responsibility for any negligent,
willful, or intentional act of my child and as a result will indemnify and hold harmless the School District for all costs, damages and attorneys fees. In the
event of an emergency, reasonable attempts will be made to contact the parent. This would not prevent the emergency health care provider from acting in
the best interests of the child. I authorize emergency medical treatment for my child in the event of accident or illness during this field trip.
Signature of Parent/Guardian Date
PBSD 0755 (Rev. 10/23/2009) SBP 6Gx50-2.40
SECTION ll - PARENT / LEGAL GUARDIAN APPROVAL
SECTION l - TRIP INFORMATION
HOME TELEPHONE NUMBER EMERGENCY TELEPHONE NUMBER
PHYSICIAN NAME
TELEPHONE NUMBER
BUSINESS TELEPHONE NUMBER
SkilledBeginning
OTHER STUDENT INFORMATION (allergies, medications, etc., be specific)
NUMBER OF CHAPERONS
FemaleMale
CELL NUMBER
+
In the event of an overnight trip, students may not be supervised while in assigned rooms.
*
Private Charter Bus
out-of-country
MEAL PROVIDED
By Parent By School
Signature of Emancipated Student Date
Signature of Parent/Guardian Date
Attach any additional pages, if needed, including any relevant provisions in the student's IEP or 504 plan.
Check here if the student wears a medical alert
