WS/FCS FIELD TRIP PERMISSION FORM OUT-OF-TOWN OR OVERNIGHT FIELD
TRIP
Dear Parent or Guardian,
Your child's class or school club will be taking a field trip to the destination described below to enrich the
curriculum or to provide an educational experience that cannot be provided within the classroom setting. Your
permission for your child's participation on this trip is requested. Please read this information carefully. If you have
any questions, you may contact the teacher by telephone or email.
Class/Club: West Forsyth Bands Faculty Sponsor: Mr. Shoemaker
Itinerary: Place(s) to be visited: Carver High School, during the school day on Thurs, Feb 27th
Transportation: Students will be transported by: [ X ] Activity Bus [ ] Commercial Coach
Student Behavior: The same rules of student conduct that apply to the behavior of students in school apply to the
behavior of students while on a field trip. Students are expected to follow all directions and instructions given by the
teachers and/or other chaperones on the trip. Failure to follow the rules of behavior, directions or instructions may
result in your child being sent home by the most reasonable and appropriate means of transportation, at the parent's
expense.
Emergency Information:
Parent's Work Phone: Home Phone: Cell Phone:
Other Person to Contact: Relation to Student:
Work Phone: Home Phone: Cell Phone:
Name of Medical/Hospital Insurance Carrier or HMO:
Telephone No: Policy No.:
1. I, the undersigned parent, give permission for my child to participate on this field trip.
2. ☐ I agree to pay the fees required for my child's participation on this field trip.
☐ I am financially unable to pay the required fees and would like information about a waiver or reduction of the fees
required for participation on this field trip.
3. I authorize my child’s teacher, ______________________________, an adult in whose care the minor child has been
entrusted during the field trip, to do any acts which may be necessary or proper to provide for the health care of the minor
child, including, but not limited to, the power (i) to provide for such health care at any hospital or other institution, or to employ
any physician, dentist, nurse, or other person whose services may be needed for such health care, and (ii) to consent to and
to authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other
procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining
procedures. This consent shall be effective only during the field trip described herein. By signing below, I indicate that I have
the understanding and capacity to communicate health care decisions and that I am fully informed as to the contents of this
document and understand the full import of this grant of powers to the agent named herein.
4. I agree to accept responsibility for and to pay any medical and/or hospital fees or charges for emergency medical care
authorized by the teacher listed above in an emergency.
5. I further agree to indemnify and hold harmless, the faculty sponsor, volunteer chaperons, the Board of Education, its
agents, employees and representatives from and against any and all claims, suits or causes of action which I or my child may
have or claim to have for any injuries arising from, out of, during or in connection with my child's participation in the field trip or
the rendering of emergency medical care or treatment, except for injuries caused by gross negligence or intentional
wrongdoing.
Special Medical Information Please list and describe any special medical information or instructions that the teacher listed
above may need to properly care for your child while on the field trip:
List any medications that need to be administered to your child
Name of Medication: Dosage:
Print Parent or Guardian's Name: Signature of Parent or Guardian:
Print Student's Name: Street Address:
Date: City: State: ZIP:
Optional. Many hospitals require that medical authorization forms be notarized. They may not provide immediate medical
care for your child at the request of the chaperone unless this form is notarized. They may wait until they are able to contact
the parent directly before providing medical care. WS/FCS requests, but does not require, that this form be notarized.
STATE OF NORTH CAROLINA, COUNTY OF FORSYTH
On this ___ day of __________, ___, personally appeared before me the named __________, to me known and known to me
to be the person described in and who executed the foregoing instrument and he (or she) acknowledges that he (or she)
executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true.
Notary Public. My Commission Expires: (OFFICIAL SEAL).
