Parent/Legal Guardian Authorization for
Student Participation and Travel
This completed form and payment (if applicable) are due on or before:
_____________________________ to ____________________________________________________________.
Permission is requested for your child to participate in the following:
Activity: _____________________________________ School: _____________________________________
Organization: ________________________________ Place: ______________________________________
Teacher/Advisor: _____________________________ Dates: ___________________ Times: ____________
Mode of Transportation: ______________________
Parental Permission
(To be completed by Parent/Legal Guardian
Name of Student: _________________________________________________ Home Phone: _____________
Emergency Contact: ____________________________________________________ Phone: _____________
Check as appropriate:
My son/daughter has permission to attend the above activity.
My son/daughter DOES NOT have permission to attend the above activity.
Medical Insurance Coverage
My child has medical coverage with: _______________________________________________________
My child is not covered by any medical insurance plan.
Private Vehicle Usage
My son/daughter may drive to the activity alone. (Form BO-4, “Application for Use of Private
Vehicle to Transport Students” must be completed and attached to this form.)
My son/daughter may ride in a vehicle driven by an adult to the activity.
I grant permission for the above named student to participate in the activity/activities listed above, and
to travel by private or commercial car, bus, train, airplane, and other means of transportation as required.
I further give permission to travel by the mode indicated above. I release the State from liability resulting
from the use of other than school vehicles pursuant to HRS 286-181.
In the case of illness or injury to above named student, I hereby consent to and authorize such treatment
as deemed necessary, and agree to pay for such medical and dental costs if incurred.
_____________________________________________________________ __________________________
Teacher Acknowledgment for Student Travel
(To be completed by subject teachers, if applicable)
Please sign below to acknowledge that the above student will be missing class because of the activity
mentioned above. He/She understands that all class work shall be made up at YOUR convenience.
Home Room: _______________________________ Period 4: ___________________________________
Period 1: ___________________________________ Period 5: ___________________________________
Period 2: ___________________________________ Period 6: ___________________________________
Period 3: ___________________________________ Period 7: ___________________________________
(Date) (Advisor/Teacher)
(Please include relationship)
(Name of plan, e.g., HMSA, Kaiser, Military, etc.)
Form SA-1, Rev. 9/09 RS 10-0308 (Rev. of RS 10-0167)
Distribution for overnight or off-island travel:
Original - Chaperone; 1 copy each to principal & parent
a. Transportation ... ($ __________ )
b. Entrance Fee ..... ($ __________ )
c. Other Costs ....... ($ __________ )
d. Total Cost .......... ($ __________ )
Print or Type Parent’s/Legal Guardian’s Name
Parent’s/Legal Guardian’s Signature Date