FIELD TRIP PARENT AUTHORIZATION AND RELEASE FORM
Form must be completed and returned to the supervising staff by ___________in order to participate in this event.
Student Name: _____________________________________ Date of Birth: ________________________________
Address: ___________________________________City: ______________________ Zip: ____________________
Field trip to: Summer School Abroad -Italy Date(s) of trip: June 5-18, 2016
Responsible JSerra teacher/staff member: Ms. Laura Kennedy
I hereby request that JSerra Catholic High School (“JSerra”) permit my son/daughter identified above to participate in the
foregoing activity. I am aware that there are certain risks associated with such participation. I hereby knowingly and voluntarily
assume any and all such risks. Moreover, for valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, I, individually and on behalf of my minor child, hereby knowingly and voluntarily release, acquit, and discharge
JSerra, and each of its officers, directors, employees, agents, volunteers, and representatives, of and from any and all liability,
claims, demands, and/or causes of action, relating to or arising from such participation.
I hereby authorize JSerra personnel, as agent for the undersigned, to consent to any x-ray, examination, anesthetic, medical or
surgical diagnosis or treatment and hospital care which is deemed advisable by, and render under the general or special
supervision of any physician and/or surgeon licensed under the provisions of the Medical Provisions Act on the medical staff of
any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required,
but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such
diagnosis, treatment or hospital care, which the aforementioned physician, in exercise of his best judgment, may deem advisable.
Parent/Guardian Name: ____________________
Parent/Guardian Signature: ____________________________
Parent/Guardian daytime telephone: ________________________
Cell phone: __________________________
Additional emergency contact: ____________________________
Phone Number: _______________________
STUDENT MEDICAL HISTORY/MEDICATION AUTHORIZATION
Allergies/medical problems/disabilities: _____________________________________________________________
I have authorized my son/daughter to self-administer the following medications: (check all that apply)
Advil _____ Tylenol _____ Tums _____Sudafed_____Claritin_____Benadryl______Triple antibiotic cream _____
Cough drops _____Eye wash _____
I have authorized my student to be administered the following prescription medication(s) (must be in original
labeled container and maintained and administered by the field trip supervisor):
_____________________________________________________________________________________________
Written authorization must be on file with Nurses Office for your student to take any medication.
Insurance Company: ____________________________
Policy Number: _______________________________
Doctor’s Name: ________________________________
Phone Number: (____)__________________________
Field Trip Medical Letter
Dear Parent/Guardian;
The FIELD TRIP PARENT AUTHORIZATION AND RELEASE FORM must be filled out to
indicate the following:
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any medical issue,
the medications the student needs during the field trip
For those students needing to take any prescription medications with them on the Field Trip, the
medication must be delivered to the JSerra Nurse’s Office THREE DAYS prior to leaving for domestic
trips or ONE WEEK prior for international travel by the parent/guardian. Failing to do so will result in
the student not being able to attend.
Please be advised that;
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All medication (prescription or over-the-counter) will be kept with and administered by a
designated field trip personnel/retreat leader and according to the physician’s order.
All medication to be in ITS ORIGINAL, PHARMACY-LABELED CONTAINER-no
medication will be accepted unidentified or mixed in with other medications.
Make sure your student knows that it is their responsibility to go to the leader for medication
administration.
This is not a nut free or food intolerant/allergy free environment. It is the student’s responsibility
to avoid the wrong foods. They may bring their own snacks if needed.
Have your student inform the field trip/retreat leader if they have special dietary needs.
Students are to attend the trip if they have an active illness with a fever of 99.6 or higher.
Student needs to be fever-free for 24 hours without the use of fever-reducing medications.
Students with Asthma/Allergies/Diabetes-These students may carry an inhaler and/or Epipen.. Bring
their inhaler and/or Epipen to the field trip/retreat. Students with Diabetes will carry a copy of their
orders, diabetic supplies and snacks.
If you have any questions or concerns please call at (949)493-9028, FAX (949)493-2763 or send an email
to nurse@jserra.org.
JSerra Catholic High School
Student Behavior Contract
TRIP LEADER: Ms. Laura Kennedy
GROUP: Peru
TRIP DESTINATION: Piura, Peru
DATE OF TRIP: either November 20-28, 2015 or March 25-April 1, 2016
MODE OF TRANSPORTATION: Plane, cars
In order to ensure that this program is a positive experience for all involved, I understand and agree to the
following while I am participating in this travel experience:
1. During this trip, I realize that I am a representative of JSerra. At all times, I will observe the rules of JSerra
as a guideline for appropriate behavior, including public and private displays of affection.
2. I will cooperate and abide by the rules/guidelines of chaperones, host families, groups and/or designated
agencies.
3. I will satisfactorily complete all study, writing or work assignments associated with this program (if
applicable).
4. I understand that possession and/or use of alcoholic beverages, illegal drugs or tobacco is forbidden.
(Violators of this rule will be sent home at the expense of parents/guardians)
5. I will dress appropriately for all activities as determined by the trip leader/head coach.
6. I will be expected to make restitution for any incurred damage to property or persons, at school or in the
home, accidental or otherwise.
7. For overnight trips, I understand that I will not be in any hotel room with a member(s) of the opposite sex.
Inappropriate behavior of a sexual nature is also grounds to be sent home at the expense of parents/guardians.
I understand that if any of the above is jeopardized by my behavior, my parents will be notified and I
will be at risk of being sent home immediately and unaccompanied at my parents/my own expense.
_________________________________________________________________________
Student Name (please print clearly)
Student Signature
Date
_______________________________________________
Parent Signature
_______________________
Date
_______________________________________________
Parent Signature
_______________________
Date