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Parent Permission Form For A Field Trip

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Parent Permission Form For A Field Trip
Parent Permission Form For A Field Trip
Name of student:
THE SCHOOL DISTRICT OF PHILADELPHIA
PARENTAL PERMISSION
School School Phone Grade/Room Date Prepared
Teacher Destination
Educational Purpose of Trip
Date of Trip Trip Itinerary (summary)
Method of Transportation Cost to Student
I understand that in case of any emergency requiring medical treatment, every effort will be made to reach
one of the people listed above. If none of these people can be contacted, I authorize the school to give
consent to treatment as deemed necessary by emergency responders.
Print Name of Parent/s or Guardian/s:
Signature of Parent/s or Guardian/s: Date:
Leave Time Return Time
Student Lunch
A copy of this form is to be kept on file until the end of the school year.
BringFree Buy$_______ Provided
TRIP INFORMATION
STUDENT INFORMATION
I.D.#: Date of Birth:
PARENT/GUARDIAN INFORMATION
Student lives with (check all that applies): Father Mother Guardian
EMERGENCY CONTACTS
If the parents/guardians cannot be reached, the school will call the people listed below. The people listed
below should be responsible individuals who can: 1) give permission to administer health care; 2) pick up your
child if your child is ill; 3) have the authority to speak on behalf of the parents or legal guardians.
HEALTH INFORMATION
If permission is granted, please provide the following medical information or if your child does not have any of
the health conditions listed below, please write none”.
Physician’s Name: Phone:
Medical/Hospital Insurance: Group: Type:
Medication/s being taken by student:
Allergies to foods, drinks, insect bites, medications, other:
Other medical information:
I have read the trip information to:
Please complete and detach the bottom part of this form and return to teacher
Name:
Home Phone:
Work Phone:
Cell Phone:
EH-80 Parental Permission (Rev. 10/06) - THE SCHOOL DISTRICT OF PHILADELPHIA
Name:
Home Phone:
Work Phone:
Cell Phone:
Check one: my child
on
may
1. Parent/Guardian: Home Address:Home Address:
Work Phone: Cell Phone:Home Phone:
2. Parent/Guardian: Home Address:Home Address:
Work Phone: Cell Phone:Home Phone:
.
may not go on this trip
Not Needed
Parent Permission Form For A Field Trip