Field Trip Consent Form

For Office Use Only

______________________
Name of student
____________
Grade
Port Charlotte Adventist School ____________
2100 Loveland Boulevard Amount
Port Charlotte, FL 33980
(941) 625-5237

Event: Walk to Kidspace Park

Date: 03/15/2019
Departure Time: 9:00am Return Time: 2:00pm
Cost of Trip: Free
Additional comments: Permission forms must be returned in order to attend school that day.
There will be no one left at the school. If your child will not be participating other arrangement
for childcare will need to be made. **Make sure that you pack a lunch or bring $4.00 for pizza,
chips, and a drink (This will go to support the 8th grade end of year trip)**
I give permission for ________________________________________ to attend this school field trip.
Name of student
I understand that my child will leave and return according to the schedule listed on this form. In granting
this permission, I assume full responsibility for any damage to person or property caused by my child.

I understand that the student accident insurance carried by Port Charlotte Adventist School is in effect for
this field trip, and I assume financial responsibility for any medical or dental expense incurred over and
above that covered by the student accident insurance plan.

While my child is away from the PCAS campus, I can be reached at:

Cell Phone: ________________________ Home Phone: ________________________

Work Phone: ________________________

I CAN CANNOT drive for this trip ________________________________________________

Name of driver and number of passengers vehicle can hold

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission for my child to
be transported to a hospital for emergency medical treatment. I wish to be advised prior to any further
treatment by a doctor or hospital. In the event of an emergency, if you are unable to reach me at the
above numbers, contact:
______________________________ _____________________ _________________
Name Relationship to student Phone Number

ADDITIONAL MEDICAL INFORMATION

Medication my child is taking at present: ____________________________________________________

Family Health Plan Carrier and Policy Number: ______________________________________________

Family Doctor: _________________________________ Phone #:

_____________________
______________________________________________ _____________________________
Signature of parent or guardian Date