| FORT ATKINSON MIDDLE SCHOOL Fort Atkinson, Wisconsin FIELD TRIP FORM |
| ________________________________ has an opportunity to go on a field trip to __________________________________________________________ on (date) ________________________. ____________________________ is the teacher. We will leave at (time) ___________________________ and return by ________________________. The cost of the trip is $______________________________. |
| PLEASE PROVIDE THE FOLLOWING INFORMATION: Parent/Guardian Name:____________________________________________ Phone: _____________________ Father/Guardian Employer:_________________________________________ Phone: _____________________ Mother/Guardian Employer: ________________________________________ Phone: _____________________ In case neither parent/guardian can be reached, whom may we contact? Name: ____________________________City: ____________________________ Phone: ___________________ Physician's Name: _________________________ City: ________________________ Phone: _______________ Dentist's Name: ___________________________ City: ________________________ Phone: _______________ Any health concerns that the school/teacher should know about? ______________________________________ ___________________________________________________________________________________________ Is the student on medication? Yes: ________ No: ______ What for? ___________________________________ Name of Medication: __________________________________________________________________________ Does the student go into shock/have problems breathing when stung by an insect? Yes: _______________ No: ___________________ Don't know: _____________________________________ If yes, it is the parent/guardian's responsibility to provide the school with medication (Epi-pen) and a medication form signed by a physician. If medication is not provided, the student will be transported by ambulance and treated in the emergency room at the nearest hospital. Your signature below will indicate that you give permission for your child to go on the trip and authorizes school district employees to call for emergency assistance which could require a doctor/dentist or emergency vehicle (ambulance and/or rescue squad). ____________________________________________________ _____________________________________ Parent/Guardian Date Complete and return by: _______________________________________________________________________ |
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