Hoosick Falls Field Trip and Emergency Consent Form
Orientation September 5th and 6th 2017
Email address
Student Last Name:
Your answer
Student First Name:
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Parent/Guardian Last Name:
Your answer
Parent/Guardian First Name:
Your answer
Grade:
Your answer
Parent Email Address:
Your answer
Contact Phone Number:
Your answer
Child's Doctor:
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Emergency Contact's Name:
Your answer
Emergency Contact's Number:
Your answer
Please check the field trip you are giving permission for child to attend:
Required
Part A: I am aware that my child will be traveling to the above checked field trip and I have read the grade level agenda for both days, Sept 5 and 6. I give consent to the Hoosick Falls staff or chaperones to act on my behalf for my child, in the event of a medical emergency. I fully release the Hoosick Falls CSD staff and its employees from any liability connection with taking action they deem necessary regarding my child’s health and safety in the event I can’t be reached, or in a situation where time is of the essence. I grant permission for emergency treatment by a rescue squad, private physician and/or medical health care center , if needed. Any such action will be taken in the best interests of my child and will be reported to me as soon as possible.
Your answer
Please note below any medical conditions and/or medications your child will need to take during the field trip. A doctor’s order and written permission need to be on file in the Health office and medication need to be in the original labeled container.
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By Placing my initials below I am giving permission for both the field trip and any necessary medical treatment that may be required.
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A copy of your responses will be emailed to the address you provided.
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