Parent Permission Form for School-Sponsored Trip Participation - Walk to The Basilica

Dear Parent or Legal Guardian:

Your son/daughter is eligible to participate in a school-sponsored activity requiring transportation to a location away from the school building. This activity will take place under the guidance and supervision of employees from The Basilica School of Saint Mary at 400 Green Street, Alexandria, VA 22314.

A brief description of the activity follows:

Curriculum Goal: Spirituality

Destination: Basilica of Saint Mary, 310 South Royal Street, Alexandria, VA 22314

Date and Time of Departure: During current and subsequent school years enrolled at The Basilica School of Saint Mary

Date and Anticipated Time of Return: During current and subsequentschool years enrolled at The Basilica School of Saint Mary

Method of Transportation: Walk or school provided transportation when indicated

Student Cost: None

If you would like your child(ren) to participate in this event, please review and complete the statement of consent below and return the form to school by pressing submit. As parent or legal guardian, you remain fully accountable for any legal responsibility which may result from any personal actions taken by the named student (s). Please be advised that parents retain the right to opt-out of any field trip planned for their children. It should also be understood, in light of world conditions, in particular threats of terrorism to Americans, it may be necessary to cancel any school-sponsored trip due to world and national developments. If restrictions are imposed, the school/Diocese will not be responsible for the loss of any monies advanced for the planned trip.

Statement of Consent*

I hereby request that my child(ren), as indicated on this form, be allowed to participate in the event described above. I understand that this event will take place away from the school grounds and that my child will be under the supervision of the designated school employee on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation. If I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment which a physician deems necessary for the well-being of my child. I understand it may be necessary to cancel any school-sponsored trip due to world and national developments and the school/Diocese will not be responsible for the loss of any monies advanced for these planned trips.

Yes No

Parent/Guardian First Namerequired

Parent/Guardian M.I.

Parent/Guardian Last Namerequired

Parent/ Guardian Phone Number:required

EMERGENCY CONTACT INFORMATION

Emergency Contact Namerequired

Emergency Contact Phone Number:required

STUDENT(S) NAME(S)

Please complete the following information for each of your children attending The Basilica School of Saint Mary.

How many students are you granting permission for?required

Student #1

Student #1 First Namerequired

Student #1 Last Namerequired

#1 Homeroomrequired

MEDICAL INFORMATION

#1 Student's Current Medical Conditions:required

#1 Name of Physician:required

#1 Physician Phone: required

#1 Insurance Company:required

#1 Insurance ID #:required

#1 Allergies (including to medications):required

#1 Indication any medication student should take during trip:required

#1 Do you request the designated supervisor of activity to administer the above on this field trip?*

Yes No

#1 Will student bring Epi-pen?*

Yes No

#1 Will student bring Inhaler?*

Yes No

#1 Will student bring Glucagon Emergency Kit?*

Yes No

Student #2

Student #2 First Namerequired

Student #2 Last Namerequired

#2 Homeroomrequired

MEDICAL INFORMATION

#2 Student's Current Medical Conditions:required

#2 Name of Physician:required

Physician Phone: required

#2 Insurance Company:required

#2 Insurance ID #:required

#2 Allergies (including to medications):required

#2 Indication any medication student should take during trip:required

#2 Do you request the designated supervisor of activity to administer the above on this field trip?*

Yes No

#2 Will student bring Epi-pen?*

Yes No

#2 Will student bring Inhaler?*

Yes No

#2 Will student bring Glucagon Emergency Kit?*

Yes No

Student #3

Student #3 First Namerequired

Student #3 Last Namerequired

#3 Homeroomrequired

MEDICAL INFORMATION

#3 Student's Current Medical Conditions:required

#3 Name of Physician:required

#3 Physician Phone: required

#3 Insurance Company:required

#3 Insurance ID #:required

#3 Allergies (including to medications):required

#3 Indication any medication student should take during trip:required

#3 Do you request the designated supervisor of activity to administer the above on this field trip?*

Yes No

#3 Will student bring Epi-pen?*

Yes No

#3 Will student bring Inhaler?*

Yes No

#3 Will student bring Glucagon Emergency Kit?*

Yes No

Student #4

Student #4 First Namerequired

Student #4 Last Namerequired

#4 Homeroomrequired

MEDICAL INFORMATION

#4 Student's Current Medical Conditions:required

#4 Name of Physician:required

#4 Physician Phone: required

#4 Insurance Company:required

#4 Insurance ID #:required

#4 Allergies (including to medications):required

#4 Indication any medication student should take during trip:required

#4 Do you request the designated supervisor of activity to administer the above on this field trip?*

Yes No

#4 Will student bring Epi-pen?*

Yes No

#4 Will student bring Inhaler?*

Yes No

#4 Will student bring Glucagon Emergency Kit?*

Yes No

Student #5

Student #5 First Namerequired

Student #5 Last Namerequired

Student #5 Homeroomrequired

MEDICAL INFORMATION

#5 Student's Current Medical Conditions:required

#5 Name of Physician:required

#5 Physician Phone: required

#5 Insurance Company:required

#5 Insurance ID #:required

#5 Allergies (including to medications):required

#5 Indication any medication student should take during trip:required

#5 Do you request the designated supervisor of activity to administer the above on this field trip?*

Yes No

#5 Will student bring Epi-pen?*

Yes No

#5 Will student bring Inhaler?*

Yes No

#5 Will student bring Glucagon Emergency Kit?*

Yes No