Peoria Unified School District #11

FIELD TRIP PERMISSION FORM

STUDENT INFORMATION

STUDENT’S FIRST NAME

STUDENT’S LAST NAME

DATE OF BIRTH (MM/DD/YYYY)

MAILING OR STREET ADDRESS/APT#

CITY AND ZIP CODE

HOMEROOM TEACHER (ELEMENTARY)

ROOM #

GRADE

MEDICAL INFORMATION

NAME OF MEDICAL INSURANCE PROVIDER

INSURANCE NUMBER

SPECIAL MEDICAL INSTRUCTIONS TO FOLLOW

LIST ALL CURRENT MEDICATIONS LIST ALL ALLERGIES (FOOD, MEDICATION, ETC)

Check here if your child MUST take medication with him/her. If so, please have the student check with the school nurse to obtain the consent form.

PARENT SIGNATURE REQUIRED I allow to attend the field trip that has been scheduled. If any illness or injury

occurs, I authorize a school representative to obtain emergency treatment for the above student at the closest medical facility unless instructed otherwise by paramedics or according to the special instructions listed above.

PARENT/GUARDIAN SIGNATURE FOR FIELD TRIP DATE

PARENT/GUARDIAN SIGNATURE FOR EMERGENCY MEDICAL TREATMENT DATE

FIELD TRIP INFORMATION

FIELD TRIP DESTINATION

The Forum at Desert Harbor 13840 N. Desert Harbor Dr. Peoria, 85381

DATE OF FIELD TRIP

11/25/16 from 9:00 A.M.-12:00 P.M. COST OF FIELD TRIP

N/A

DEPARTURE TIME FROM SCHOOL

N/A students provide their own transportation

RETURN TIME TO SCHOOL

N/A

LUNCH WILL BE PROVIDED? YES NO

ORGANIZATION/GROUP SPONSORING TRIP (IF APPLICABLE)

National Honor Society

TEACHER IN CHARGE

Raleigh-Walton-Gilsdorf

TEACHER/ADULT TO STUDENT RATIO

(EXAMPLE: 1/10) 1/15

PURPOSE OF FIELD TRIP

To holiday decorate for the residents of the Forum at Desert Harbor. High School (only) Teacher Permission (Teacher initial by class

period) Period 1 2 3/4 5 5

EMERGENCY CONTACTS

For precautionary measures, please provide us your phone number at home OR the phone number where you may be reached on the day of the field trip. In addition, please provide us one or two other contacts (a relative, friend, or sitter, etc.)

and their phone numbers in case of an emergency. NAME OF PARENT/GUARDIAN TO CONTACT

PHONE NUMBER OF PARENT CONTACT

INDICATE PHONE # TYPE HOME WORK CELL

NAME/RELATIONSHIP ADDITIONAL CONTACT

PHONE NUMBER OF CONTACT

INDICATE PHONE # TYPE HOME WORK CELL

NAME/RELATIONSHIP ADDITIONAL CONTACT

PHONE NUMBER OF CONTACT

INDICATE PHONE # TYPE HOME WORK CELL

PUSD SPONSORED TRAVEL

Water facility usage is permissible while traveling if activity is staffed with certified lifeguards.

STUDENT’S SWIMMING ABILITY STATEMENT - REQUIRED if traveling to Water Facility

There are inherent risks in using water facilities. If you choose to have your child participate, you accept those risks. By marking one of the boxes below, you are indicating your child’s ability to swim or to be near any pool of water:

NONE AND SHOULD NOT BE NEAR ANY AMOUNT OF WATER BEGINNER LEVEL AND STILL NEEDS CLOSE SUPERVISION WHILE IN THE WATER INTERMEDIATE LEVEL WITH SUPERVISION WHILE IN THE WATER ADVANCED SWIMMER WITH LITTLE SUPERVISION NEEDED IN THE WATER

4/20/2011 3:00 pm k-12

Peoria Unified School District #11

RULES AND REGULATIONS for Water Park Field Trips

The following list of rules and regulations that students who are on a field trip to a water park are expected to follow at all times during their visit. Failure to comply with the park’s Rules & Regulations may result in removal from the park without refund. For a complete list of park rules and regulations, visit Guest Services which should be located at the park’s main gate. Note: the following items marked with an asterisk are specific to the Wet ‘n’ Wild Water Park.

Read and obey all posted rules and instructions given by the park staff.

Appropriate bathing suits are required. No shorts, cutoffs, or items with metal fasteners, rivets, zippers or buckles are allowed on the slides.

For all guests, smoking is only permitted in the designated area outside the main gate.

Containers, food, drinks or picnic lunches may not be taken into the park. Guests with special diets, baby formula or baby food may bring their items in to the park.

All bags, backpacks, and packages are subject to inspection prior to entering the park. As a reminder, for the safety of our guests the following items are not permitted inside the park: Weapons, sharp objects, hazardous items or materials, or any other item that may be perceived as a weapon.

In keeping with the family atmosphere of the park, inappropriate actions such as offensive or profane language and/or gestures as well as unruly behavior including horseplay will not be tolerated.

Please shower prior to enjoying the pools and attractions.

Some facilities may have additional participation guidelines relating to health, physical ability, etc.

PARTICIPATE SAFELY

As a guest, you are responsible for your own safety. Instructional signage is posted at each attraction. Please listen to and obey all lifeguard instructions. Please read and follow all posted safety information. Inappropriate or unsafe behavior will not be tolerated and is subject to immediate removal from the Park without refund.

We encourage the use of a “buddy system” for large groups.

Establish a “home base” at the Park for students to know school staff location.

Attraction height and weight restrictions as well as child life vest requirements apply on certain attractions.

Running and horseplay are not permitted.

It is strongly recommended that all weak or non-swimmers wear a Coast Guard approved life vest. Complimentary life vests are available. Please see a lifeguard for assistance. Floaties, water rings, and other floatation devices are not permitted. Only Park issued rafts are permitted. Water wings, masks, snorkels, and other SCUBA equipment are not permitted. Coast Guard approved “puddle jumper” style floatation devices are permitted for use.

* Many rides at Wet ‘n’ Wild are dynamic and thrilling and may include features such as high speeds, steep drops, sharp turns, and other forces. There are inherent risks in participating in any amusement attraction. If you choose to participate, you accept these risks.

Zero tolerance policy

Actions, language, behavior or conduct that interferes with a family atmosphere will result in the ejection of the offending person without refund or any other compensation. This includes, but is not limited to: offensive clothing, profanity, vulgar gestures, running, spitting, fighting and line breaking. Holding a place in line is not permitted. If you leave the line for any reason, you will lose your position and will need to start at the end.

4/20/2011 3:00 pm k-12