** SNOW DATE is Wednesday, March 18, 2015 **

HOLLIS BROOKLINE HIGH SCHOOL

FIELD TRIP PERMISSION FORM
STUDENT NAME__________________________________________

DATE OF BIRTH__________________

The above named student has my permission to attend the trip/field trip to: State Math Meet at Plymouth State University
Date(s) of the trip: Tuesday, March 17th, 2015**

Teacher: Mrs. Plummer & Mrs. Mooers_ Class: Math Team

Parent(s) Name: ___________________________Home # _______________Work #______________Cell #_____________

PLEASE LIST THE NAME AND PHONE # OF AN EMERGENCY CONTACT PERSON IN CASE A PARENT/
GUARDIAN IS NOT AVAILABLE:
NAME______________________________________________PHONE #________________________________________
ALL STUDENTS MUST RIDE ON THE BUS UNLESS OTHER ARRANGEMENTS ARE MADE PRIOR TO TRIP.
EMERGENCY MEDICAL INFORMATION
To provide the quickest possible care in the event of an emergency while at this event, this information MUST be completed
and handed to the supervising teacher before the student is allowed to attend this event. THANK YOU.
1.

Does your child have any food, medicine or insect allergies? If yes, please explain.

2.

List all medication that must be given while attending this event.

3.

List all medication that must be taken in an emergency situation (i.e. allergic reaction, bee sting, etc.)

4.

Does your child need limited physical activity due to heart problems, asthma, illness, surgery, fracture, etc.?
If yes, please explain: ___________________________________________________________________________

In the event of a medical emergency, I give my permission to licensed emergency medical authorities to administer first aid
to my child. I also give permission to a licensed physician to order whatever emergency care is deemed necessary by him/her
in the care of my child, to include the administration of medication, diagnostic procedures, anesthesia, as well as surgery, as
long as every attempt has been made to reach me. I will not hold responsible any authorized school personnel,
Hollis/Brookline School District, or school appointed volunteer chaperones for any injury or repercussion from medical
attention. I also give my permission for authorized school personnel to transport my child to a medical facility for the purpose
of obtaining medical care following an injury or medical emergency.
DISCLAIMER
In signing this form, I am aware that it may be used for medical emergencies and that treatment for my child may be within
or out of the State of New Hampshire. In signing this form, I give permission for my child to attend this event(s) and agree
that he/she will be responsible for abiding by all school rules as well as any rules outlined in the specific trip description.
We acknowledge that these activities have risks of injury associated for those who participate, including transportation from
and to the school. We understand that while every reasonable precaution will be taken to ensure my childs safety and well
being, no activity is risk free. We understand the risks and requirements for our child to participate in this/these
activity/activities.
We the parents/guardians and I, the student, have read the guidelines for this trip as outlined on this form and information
specific to this trip. I, the student, agree to abide by these rules and fully co-operate to ensure the safety and enjoyment of all
involved.

____________________________________________________
Signature of Parent/Guardian
Date
2/20/2015

___________________________________________
Signature of Student
Date