Angkor Wat Trip 2015 Permission Form

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This form acts as the Permission Slip for both the trip and the training sessions.
Please complete a separate form for each child.

Name of Student *

Class *

G4 Bridget

G4 Simon

G4 Alison

G5 James

G5 Emily

G5 Melinda

Your email address for contact information *

Additional email address for contact information (if appropriate)

Phone number for contacting you. *

Additional phone number for contacting you.

Bike Ride - does your child wish to participate in the 17 or 30km bike ride? *

Yes

Unsure at the moment - will attend the training sessions and then decide

Medical Insurance *

In order to go on overnight trips, students must be insured. If they don’t have insurance, school can purchase medical travel insurance. Please indicate your student’s insurance status

My child has insurance including medical evacuation cover (details provided below)

My child does NOT have insurance - I would like the school to purchase medical travel insurance for my child ($15). I understand that I need to pay this money to the finance office. This insurance does NOT include medical evacuation. If transport to a medical facility (medical evacuation) becomes necessary, I understand that ISPP will take such action as they consider necessary to arrange transport to a medical facility, and I agree I will pay all costs.

Medical Insurance if you have medical insurance can you please complete the details below

Name of Insurance company

Policy Number

Company phone number

Medical Information

Please write below any allergies the student may have:

Please write below any pre-existing medical condition of which teachers should be aware

Please note other considerations or conditions - ie travel sickness

Details of any medication your child is taking

Permission - by ticking the box below, it is your equivalent of your written signature (this applies to all training sessions and the actual trip) *

The staff members accompanying the ISPP students on this field trip will endeavor to provide a rich educational and cultural experience for the participants. Reasonable precautions will be taken to assure the students’ safety and care. In case of unforeseen occurrences, the staff will take all measures to assist students. However, the staff of ISPP are not to be held liable for incidents beyond their control of responsibility. Parents are expected to assume any and all responsibilities for their children, including financial, regarding actions outside the context of this tour. Students are expected to conform to the rules and guidelines set forth for this field trip. In the event of illness or injury, a reasonable effort will be made to contact you to obtain consent in advance of medical services being given. If we are unable to contact you, the teacher(s) will consent to such services for your child by acting on your behalf based on your written advance authorization. That authorization is by ticking the box on this consent form. I/We, the parent(s) or legal guardian(s) of grant permission for him/her to participate in the 2015 Angkor Wat Trip. I/We have read the above and hereby designate the teacher sponsor(s) for ISPP to act on my/our behalf in the event of a medical emergency. He or she may authorize such medical attention as may be required in an emergency because of illness or injury sustained by my son/daughter while practicing in this field trip. I hereby assume all financial responsibility for any medical attention or treatment that might be required. As the parent(s) or guardian(s) of the above named student, I concur with the information noted above, and I understand that all ISPP school policies and procedures will be in force during the school sponsored activity.

Yes, I give my permission to the above

Parent's name completing this form *

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