Fillable Student Permission Form for Field Trip (One Day (Poudre School District)

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Student Permission Form for Field Trip (One Day (Poudre School District)

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August 2015 Page 1: For Parent to Keep
Risk Management
2407 LaPorte Ave
Fort Collins CO 80521
970.490.3506
Student Permission Form for Field Trip
(One Day or Less)
Note to Parent/Guardian: In order for your child to participate in this field trip, you must complete Emergency Contact
and Permission section on Page 2 of this form and return the completed form by:
School: Field Trip to:
Teacher: Phone Number:
Date of Field Trip: Departure Time: Return Time:
Will this field trip occur outside of normal school hours? No Yes
Grade: Estimated # of Students:
Activities Involved:
Tr
ansportation:
Private Vehicle* PSD Bus
Parent/Guardian Responsibility
Walking Public Transportation Other:
* Select all that apply from the following:
PSD Employee PSD Parent Volunteer PSD Student
Each driver must complete the required form(s) and be approved by the building principal.
*Name of Driver:
Special Instructions (e.g., items students should bring):
Special Procedures and Considerations
Your child’s participation in the field trip is voluntary. Your written consent on the second page of this form is necessary
for your child to participate.
• Field trips may potentially involve risks
and
responsibilities for your child that are beyond the
scope of those normally associated with educational
activities at school. Such risks include the potential
for personal injury and/or damage to personal
property. You are encouraged to inquire in advance
concerning the nature, details, and potential risks of
this field trip.
•
Your child shall be subject to the Poudre School
District Code of Conduct at all times related to his/
her participation in the field trip. As a condition of
participating in the field trip, your child shall also be
required to comply with all instructions and safety
precautions communicated by school officials.
• The School District is
protected
from liability under
the
Colorado
Governmental Immunity Act for injuries and damages that may arise
out of or in connection with the field trip, and any injuries or damages
arising out of or in connection with the field trip may therefore not be
covered by School District insurance. For these reasons, it is
recommended that you obtain appropriate insurance from qualified
sources to cover medical expenses and other costs that could result
from injury to your child, and damage to or destruction of property
belonging to you or your child, which may arise out of or in connection
with your child’s participation in the field trip. The School District has
information available regarding accident and health insurance
that may be purchased to cover your child’s participation in the
field trip. You may enroll at https://www.psdschools.org/risk-
management/student-insurance.
Principal Review:
Approved # of Adult Chaperones Required: Denied
Special qualification required of chaperones OR reason(s) for denial:
Principal’s Signature: Date:
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signature
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August 2015 Page 2: Return to the School
Field Trip To: Field Trip Date:
Teacher: Phone Number:
Emergency Contact and Permission
Emergency Contact Information:
Parent/Guardian: Cell Phone:
Work phone: Home phone:
Parent/Guardian: Cell Phone:
Work phone: Home phone:
Other Contact: Cell Phone:
Work phone: Home phone:
Is this Field Trip occurring outside normal school hours? No Yes
If Yes:
My child will not need any medications administered during this field trip.
My child will need medication(s) administered during this field trip and:
I will be attending the field trip and will be responsible for carrying and administering the medication(s) to my
child.
I will be attending but will not be responsible for carrying and administering the medication(s) to my child and
will need a District employee to carry and administer the medication(s).
I will not be attending and will need a District employee to carry and administer the medication(s).
Field Trip Permission and Assumption of Risk:
I hereby grant permission for my child, , to participate in the field trip
and associated activities described on page 1 of this form, subject to the Special Procedures and
Considerations specified on page 1 of this form. In consideration of Poudre School District allowing my child to
participate in the field trip and associated activities, I hereby release and hold harmless the School District and
its board members, employees and agents from any and all liability, claims, causes of action, damages and
demands of any kind whatsoever (except willful and wanton acts or omissions) that may be brought by my child
or on my child’s behalf for any and all damages, including personal injury to my child, arising out of or in
connection with my child’s participation in the field trip and associated activities. My child and I understand and
appreciate the risks and dangers of my child’s participation in the field trip and associated activities, and
assume the risk of any and all damages, including personal injury, which the
child may incur as a result of such
participation.
Signature of Parent/Legal Guardian Date
Signature of Student (if over 18) Date
Original — Keep on file at school for 3 years.
Forward original to Risk Management if any incident occurred on this field trip involving this student.
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Student Permission Form for Field Trip (One Day (Poudre School District)

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Completed 14 December 2021

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