CENTRAL HIGH SCHOOL
FIELD TRIP PERMISSION FORM
Sponsor’s Name ___________________________ Organization ___________________________
I, ________________________________, give my child, _____________________________, permission to
participate in the following Central High School field trip on ______________________ to
(Date)
______________________________________________
(Name of Trip or Destination)
I understand, as does my child, that like other school activities, field trips are school sponsored events and
therefore all Wise County Code of Conduct and school rules and regulations apply to each event. If my child
does not conform to the rules and regulations, he/she will be subject to disciplinary action.
I also give my permission for any emergency medical treatment that may be necessary for my child while
participating in the above mentioned activity. I realize that every effort will be made to contact me in case of a
medical emergency and that treatment would be at my expense.
______________________________________ ________________________
Parent’s Signature / Date Home Phone Number
______________________________________ __________________________
Student Signature / Date Emergency Phone Number
______________________________________ __________________________
Family Doctor (Name) Date of Last Tetanus Shot
______________________________________ __________________________
Health Insurance Company Health Insurance Policy Number
Please list any special medical information you feel the sponsor should know, such as allergic
reactions to medications or any medications that must be taken on a regular basis.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Teacher approval and sign-off section:
____________________ ___________________ __________________ ___________________
Block 1 Teacher Block 2 Teacher Block 3 Teacher Block 4 Teacher