Lexington Public SchoolsField Trip Health and Permission Form

School: Grade: Teacher:

Student’s Name: Date of Birth:

Address: Home Telephone:

Parent/Guardian Name: Parent/Guardian Name:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

If you plan to be out of town during any part of the field trip, please indicate how we may contact you.If you plan to be out of town during any part of the field trip, please indicate how we may contact you.

General Health Information:General Health Information:General Health Information:General Health Information:General Health Information:

Date of most recentTETANUS shot:

Known allergies: Physical limitations: Known health problems: Other:

Insurance Information (required for all participants):Insurance Information (required for all participants):

Insurance Company Name: Insurance Policy Number:

Physician’s Name: Physician Telephone:

Dentist’s Name: Dentist’s Telephone:

Emergency Contacts:Emergency Contacts:

Name: Telephone:

Name: Telephone:

Medical Information:

The Lexington Public Schools’ Field Trip Policy requires that medication for any child in grades K-8 be submitted to the school nurse prior tothe trip. If this is an emergency medication (i.e., inhaler, Epi-pen, etc.), please indicate whether the student has been instructed on how toself-administer and if he/she may do so: Yes __________ No __________

Does your child have any current medical condition that requires medication during the duration of the field trip?

Yes, School Order on File __________ Yes __________ No __________

If yes, please describe the nature of the condition and provide specific instructions for the dispensing of medication while on this trip.Medication ________________________________________ Dosage ________________________________________Reason for taking medication ______________________________________________________________________________Prescribing physician ________________________________ Telephone ______________________________________Time(s) to be dispensed __________________________________________________ (specify morning/afternoon/evening)Period of time: from ____________________ to ____________________Students needing to self administer medications on an out of state field trip: Student will hold medication __________ Chaperone will hold medication __________Physician’s Signature (only required for overnight trips) ______________________________ Date ______________________________Parent/Guardian’s Signature ___________________________________________________ Date ______________________________

Field Trip Emergency:Should an emergency arise in which treatment by a qualified physician is required. I herewith give permission for my child, ____________________ to receive treatment, and I herewith give his/her teacher/chaperone permission to act in my name during the period of the field trip. Every effort will be made to contact parents prior to reaching a decision of this nature.

Field Trip Permission:I give my child, named above, permission to travel on the field trip to ______________________________ on ______________________________.

Parent/Guardian Signature: ____________________________________________________ Date: ______________________________PAYMENT MADE BY: CHECK __________ or ONLINE PAYMENT __________

The Release from Liability and Indemnity Agreement must be completed on the reverse side

Last revision: January 26, 2011

Lexington Public Schools

Consent Form and Release from Liability and Indemnification for Extra-CurricularField Trips and Activities

Student Name: ___________________________________________________________________________________

Parent/ Guardian Name: ___________________________________________________________________________

Academic Field Trip/ Activity: ______________________________________________________________________

This is a (select one): __________ single day field trip/ activity; __________ overnight field trip/ activity

As the undersigned parent/ guardian of the above-listed Student, I hereby consent to his/her participation in the above-listed extra-curricular field trip/ activity and do forever RELEASE, acquit, discharge, and covenant to hold harmless theTown of Lexington and the Lexington Public Schools from any and all actions, causes of action and claims on account of,or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which Imay now or hereafter have as the parent/ guardian of the Student, and also all claims of right of action for damages whichthe Student has or hereafter may acquire, either before or after he/she has reached his/her age of majority resulting fromhis/her participation in the Lexington Public Schools extra-curricular field trip/ activity. I acknowledge the Student’s participation in this extra-curricular field trips/ activity is voluntary and that his/her participation is not required.

I acknowledge that the provisions of the Student Handbook will remain in effect while the Student participates in extra-curricular field trips/ activities. I further acknowledge that possession and/ or use of any controlled substance or alcoholis strictly prohibited during all extra-curricular field trips/ activities.

Additionally, in consideration for allowing my Student to participate in the above-listed extra-curricular field trip/ activity,I, as the legal representative of my Student, agree to indemnify the Town of Lexington, the Lexington Public Schools andits employees, agents, including elected officials, in the event that any action, charge, and/or claim is brought against theforegoing, which is in any way related to, arising from and/or growing out of, directly or indirectly, my Student’sparticipation in the extra-curricular field trip/ activity run by, sponsored by or related to the Lexington Public Schools.

I agree to allow school personnel for the extra-curricular field trip/ activity to authorize medical care for myStudent and/or return travel to Lexington, MA if they, in their sole discretion deem it to be in the Student’s best interest. I agree to promptly reimburse school personnel for all expenses incurred for services and/or return travel to Lexington, MA for the Student.

Overnight and/ or Foreign Travel

This Parental/Student Consent and Release of Liability and Indemnity Agreement covers all trips outside of Lexington, MA, including travel to one or more foreign countries. By signing this form, Parents and Student acknowledge that theyare aware of the risks of foreign travel and have been informed by the school department that decisions with respect to such travel are up to each parent and student. Parents and students have been advised to avail themselves of advice and information from the Office of the U.S. Secretary of State.

__________________________________________ _______________________________________________Parent Signature Date Student Signature (required in 18 or older) Date

The Field Trip Health and Permission Form must be completed on the reverse side

Last revision: January 26, 2011