FORMS REQUIRED FOR FIELD TRIPS

Transcription

1 FORMS REQUIRED FOR FIELD TRIPS 15

2 FIELD TRIP/SCHOOL ACTIVITY PARENT CONSENT/LIABILITY WAIVER/MEDICAL RELEASE OVERNIGHT OUT-OF-STATE OFF CAMPUS Student School Club/Group/Class Supervising Faculty Member Activity Location & Time of Departure & Time of Return Method of Transportation : School Bus Charter Bus Private Car Leased Vehicle Walking Other MEDICAL INFORMATION Does your child have any of the following conditions? Epilepsy/Seizures Yes No Motion Sickness Yes No Diabetes Yes No Any Medication Yes No Asthma/Wheezing Yes No Heart Disease Yes No Muscular/Skeletal Problems Yes No Hemophilia/Bleeding Disorders Yes No Allergies: Is there any other condition which might possibly require treatment and/or medication during the trip? Yes No If yes, you must complete and attach the Administration of Non-Prescription Medication Consent Form and/or the Administration of Prescription Medication Consent Form. PARENT CONSENT / LIABILITY WAIVER / MEDICAL RELEASE I/We hereby give permission for my child to accompany employees of the LCSB, acting as chaperones, to for the days indicated above. I/We will not hold the LCSB nor their agents or employees accompanying the group responsible for any accident or injury to my child/ward. In the event my child/ward causes any property damage or personal injury, whether individually or in concert with other persons or entities, I/we agree to indemnify and hold harmless the LCSB, its agents and employees. I/We have read all the information in regards to this trip. I/we are aware of guidelines of said trip and the number of chaperones which will accompany my/our child/ward. I/We hereby grant permission to the attending physician or his consulting physicians, to render to my/our child/ward any emergency treatment, medical or surgical care that might be deemed necessary to the health and well-being of said child/ward. Also, when necessary for the administering of such care, I/we grant permission for hospitalization at an accredited hospital. I/We assume full responsibility and liability for any and all expenses, damage, accident, illness, injury or medical expense of and to my/our child/ward or my/our property resulting from such participation. I/We attest and affirm that the participant has no limitation that should prevent participation in the activity and I/we have not been advised or informed by anyone to the contrary. I/We further agree to inform the appropriate school official(s) should my/our child/ward s physical condition change in any way and any time so as to affect his/her participation in the activity herein named. I/We further relieve and release said LCSB from any liability in its failure to carry insurance upon my/our said child/ward. Our/My child/ward has medical insurance Yes No If yes, you must complete and attach a copy of proof of insurance to this form. Insurance Co Policy # Home Phone Work Phone Cell Phone Emergency Phone Parent/Guardian Name (Please Print) Parent/Guardian Name (Signature) Home Address / City / Zip THIS SECTION MUST BE COMPLETED BY PARENT/GUARDIAN ONLY IF CHILD/WARD IS GOING OUT-OF-STATE OR OVERNIGHT! (SIGN IN PRESENCE OF A NOTARY) Parent/Guardian Signature NOTARY STATEMENT STATE OF FLORIDA, COUNTY OF LAKE On before me personally appeared, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the instrument and acknowledged to me that he/she executed the same in his/her authorized capacity and that by his/her signature on the instrument, the person or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal One copy must be retained by the administration and a duplicate copy must accompany the sponsor when leaving school property with student 75 F004 03/13/14 NEW Submitted by Risk Management 16

3 ADMINISTRATION OF NON-PRESCRIPTION MEDICATION CONSENT FORM Non-prescription medication may be administered at school by school personnel when such medication is necessary for school attendance and cannot otherwise be accomplished. The non-prescription medication may be administered for 72 consecutive hours, once in the school year. Medication must be brought to school by parent/guardian in a sealed, unopened container. A form must be completed for each medication administered. Student Name Parent/Guardian Address DOB Phone Emergency Phone Name of non-prescription medication Dose to be given Diagnosis Time(s) to be given Allergies Purpose/reason for this medication APPENDICES Discontinue date Instruction(s) (i.e. take with water, milk, food) What reaction(s) may occur, if known? I request Lake County Public School personnel administer medication as directed by this authorization. A doctor s signature is required if: A medication is necessary beyond the 72 consecutive hours or When medication needs to be taken on Field Trips If there are questions regarding this medication I authorize the School Nurse/District Nurse to contact ordering physician as needed throughout the school year. It is the parent s responsibility to pick up medications that are no longer needed at school. Medications that have expired and/or are discontinued during the school year will be disposed of within a week of the expiration or discontinuation date. At the end of the school year left over or unused medications will be disposed of immediately after the last day of school. Signature of Parent/Guardian (REQUIRED) Physician signature (REQUIRED) Physician s Official Stamp MIS Form 61D003 03/16/16 RVS Submitted by Student Services 14

4 ESCUELAS DEL CONDADO DE LAKE FORMULARIO DE CONSENTIMIENTO PARA LA ADMINISTRACION DE MEDICAMENTO SIN RECETA El medicamento sin receta puede ser administrado en la escuela por un personal de la escuela cuando dicho medicamento es necesario durante el horario de la escuela y no pueda ser logrado de otra manera. El medicamento sin receta puede ser administrado por 72 horas consecutivas, una vez durante el año escolar. El medicamento debe de ser llevado a la escuela por el padre o persona encargada en el envase original sellado y sin abrir. Es necesario completar un formulario por cada medicamento administrado. Nombre de Estudiante Padre/Persona Encargada Dirección Fecha de Nacimiento Teléfono Teléfono de Emergencia Nombre de medicamento sin receta Dosis que ha de darse Diagnostico Hora para dar Alergias Propósito o la razón de medicamento Fecha de descontinuar Instrucciones (por ejemplo tomar con agua, leche, comida) Que reacción(es) puede ocurrir que usted esté al tanto? Solicito que el personal de las Escuelas Públicas del Condado de Lake administre el medicamento según las indicaciones en esta autorización. Se requiere una firma del doctor si: El medicamento es necesario por más de 72 horas consecutivas o Cuando es necesario tomar el medicamento durante un día de pasadías Si hay alguna pregunta acerca de este medicamento yo autorizo a la enfermera de la escuela o del distrito comunicarse con el médico mientras sea necesario durante el año escolar. Es responsabilidad de los padres recoger los medicamentos que ya no son necesarios en la escuela. Los medicamentos que han expirado y / o descontinuado durante el año escolar serán eliminados una semana después de la expiración o fecha de discontinuación. Al final del año escolar los medicamentos no utilizados serán desechados inmediatamente después del último día de clases. Firma de Padre o Persona Encargada (REQUERIDO) Firma de Médico (REQUERIDO) Fecha Fecha Sello Médico s Oficial MIS Form 61D003 03/16/16 RVS Submitted by Student Services 15

5 ADMINISTRATION OF PRESCRIPTION MEDICATION CONSENT FORM Medications must be brought to school by the parent; NEVER by the student. The medication must be presented to school personnel in the original container with a current date. Metered inhalers should have the label affixed to the inhaler for easy identification or must be in the original box with prescription label. The parent must give the first dose of prescription medication at home. Under no circumstances will the school accept more than a four-week (30 days) supply of prescription medication. Parents may request that the pharmacist dispense two labeled bottles for medication, one for home and the other for school. Student Parent Address Home Phone Name of medication Dosage to be given Diagnosis to start DOB School Work Time to be given Allergies Last date to be given Please circle one: may may not carry and use the inhaler himself/herself. Special instructions on administration of medication (i.e. to be given after lunch, do not chew, to be given with food, etc.) Reaction(s) that may occur I request Lake County Public School personnel to administer medication as directed by this authorization. If there are questions regarding this medication I authorize the School Nurse/District Nurse to contact ordering physician as needed throughout the school year. It is the parent s responsibility to pick up medications that are no longer needed at school. Medications that have expired and/or are discontinued during the school year will be disposed of within a week of the expiration or discontinuation date. At the end of the school year left over or unused medications will be disposed of immediately after the last day of school. Parent Signature Physician Signature Physician s Official Stamp MIS Form 61D001 03/16/16 RVS Submitted by Student Services 16

6 ESCUELAS DEL CONDADO DE LAKE FORMULARIO DE CONSENTIMIENTO PARA LA ADMINISTRACION DE RECETA MEDICA Medicamentos deben de ser traídos a la escuela por un padre; NUNCA por el estudiante. El medicamento debe de ser entregado a un personal de la escuela en el envase original con fecha actual. El inhalador debe de tener la etiqueta fijada al inhalador para poder identificarlo fácilmente o debe de ser mantenido en su caja original con la etiqueta del medicamento. Es necesario que el padre de la primera dosis del medicamento al estudiante en la casa. Bajo ninguna circunstancia la escuela podrá aceptar una receta de medicamento con una cantidad de más de cuatro semanas (30 días). Los padres pueden solicitar que el farmacéutico dispense dos envases con etiquetas del medicamento, uno para la casa y el otro para la escuela. Nombre de Estudiante Padre Dirección Teléfono de la Casa Nombre del medicamento Dosis que ha de darse Diagnostico Fecha de comenzar Fecha de Nacimiento Escuela Trabajo Hora para dar Alergias Fecha de última dosis Favor de circular una: si puede no puede llevar y utilizar el inhalador él/ella mismo/a. Instrucción especial de administración de medicamento (por ejemplo, después del almuerzo, no se debe de masticar, debe ser tomado con la comida) Reacción que pueda ocurrir Solicito que el personal de las Escuelas Públicas del Condado de Lake administre el medicamento según las indicaciones en esta autorización. Si hay alguna pregunta acerca de este medicamento yo autorizo a la enfermera de la escuela o del distrito comunicarse con el médico mientras sea necesario durante el año escolar. Es responsabilidad de los padres recoger los medicamentos que ya no son necesarios en la escuela. Los medicamentos que han expirado y / o descontinuado durante el año escolar serán eliminados una semana después de la expiración o fecha de discontinuación. Al final del año escolar los medicamentos no utilizados serán desechados inmediatamente después del último día de clases. Firma de Padre Firma del médico Fecha Fecha Sello Oficial del Médico MIS Form 61D001 03/16/16 RVS Submitted by Student Services 17

7 Submit at least TWO WEEKS PRIOR to date of trip. FIELD TRIP AND BUS REQUEST FORM Curriculum & Instruction Copy School Type of Trip: Educational Trip Curriculum Area Athletics (Specify) of Request Band Chorus Other (Specify) of Trip Destination Number of persons to be transported: Adults Pupils Teacher(s) in charge: Method of Transportation: Students and Adults in privately owned cars (Subject to adequate liability insurance on private vehicles.) School Buses Indicate A.M. or P.M. Number of buses required Time of Departure: Time of Return: Driver(s): Parent permission and waiver forms will be required for each student. FUND SOURCE: Budget Int. Accts. Other FUND (to be completed if budget checked) COST FUNCTION OBJECT CENTER PROJECT PROGRAM Signature of Principal Approved Not Approved Curriculum Supervisor Approved Not Approved Transportation Supervisor *TO BE COMPLETED BY TANSPORTATION DEPARTMENT* School Bus Number: Driver(s) Odometer Reading: Beginning Ending Miles Drivers Retirement/Social Security Total Cost.. $ $ $ $ Remarks MIS Form /20/04 REW Submitted by Transportation 19

8 REQUEST TO TRANSPORT STUDENT(S) IN PRIVATE VEHICLE Name of School Name of Driver Home Phone Other Phone Address Event (s) of Event Origin Destination I request permission to transport up to (maximum number of passenger restraints) student(s) in the following described private vehicle for this event: Make Model Year License Tag# State Insurance Company Policy# Policy Exp. To my knowledge, my vehicle meets the requirements of the Department of Education & Department of Transportation. I reviewed this information at the LCSB website under Risk Management at I understand that the student(s) will be transported only in designated seating positions and I will require the student(s) to use the vehicle manufacturer s crash protection system (lap/shoulder belts). I also understand that student(s) 12 and under should ride buckled up in the back seat if my vehicle has front passenger air bags. I am aware that children under 40 pounds and/or age four and under must be in appropriate child safety seats. While using or operating a motor vehicle with the approval or authority of the school district on a school function, I understand that I am not covered for third party liability damages in excess of my required coverage. I understand that it is my personal insurance providing coverage for liability and injury. I certify that the vehicle being used for the purpose indicated is covered by liability insurance with limits of at least $100, per person, $300, per occurrence for bodily injury and $50, coverage for property damage. I have completed and passed a Level II Volunteer Clearance for the LCSB, I declare that I have read the above form and that the facts stated therein are true. Driver Signature Each student s parent or guardian must be notified in writing of the transportation arrangements and written consent has been obtained from the student s parent or guardian. Supervising Faculty Member Signature A photocopy of the driver s valid driver s license and insurance card is attached to this form with a list of students to be transported. APPROVAL TO TRANSPORT STUDENTS Approval is granted for the above-listed driver to transport student(s) in the private vehicle and only for the event shown above. 75 F002 01/15/10 NEW Submitted by Risk Management Verified by School Volunteer Coordinator Principal/Designee Signature 20

9 FIELD TRIP SPONSOR FORMS 21

10 SPONSOR CHECK LIST OVERNIGHT - OUT OF COUNTY SCHOOL YEAR School Name Submitted Staff Member Name/Title Work Ext. & Cell Number Field Trip Destination City, State Departure /Time Return /Time FIELD TRIP PLAN MUST HAVE APPROVAL FROM SCHOOL PRINCIPAL/DESIGNEE Name of class/club/group attending Trip roster is attached. Number of students Number of chaperones Mode of Transportation Number of LCS Buses Charter Bus (Approved LCS Vendor) Personal Vehicle (no more than 20 students per trip) Rental Vehicle (Approved LCS Vendor) The following items must be attached for Principal/Designee review prior to approval of field trip. If using a Charter Bus Company a copy of transportation information to include number of buses and name of company is attached. If using private automobiles: A list of driver s is attached. All volunteer drivers have completed the following: application and background clearance on record with LCSB. (77 E001) the Level II application process as required by LCSB policy. are cleared and approved by the LCSB Human Resource Department. Copy of a valid driver s license and car insurance for each driver is attached. Copy of the completed Request to Transport Student(s) in Private Vehicle Form for each driver is attached. (75 F002) The vehicle must meet the requirements of the Departments of Education and Transportation. This information is available on the LCSB website under Risk Management at If using leased vehicles: The leased vehicle is from a LCSB approved vendor and is leased in the name of the school district. A copy of the lease agreement is attached. A list of drivers is attached. All drivers are LCSB employees. Lay coaches may not drive leased vehicles. For each leased vehicle there must be two (2) LCSB employee drivers. No more than eight (8) occupants in any vehicle. All occupants must have their own seat belt. Page 1 of 2 75 F006 04/29/10 REV Submitted by Risk Management 22

11 OVERNIGHT - OUT OF COUNTY SPONSOR CHECK LIST A written statement is attached identifying how this field trip is academically beneficial to students. A written plan is attached identifying how students will be returned to school in the event of an emergency or disciplinary incident. A copy of the written communication sent to parents acknowledging the total cost of the field trip, including refund penalties for withdrawing from the trip, is attached. The funding source and fundraising information is attached. No child will be excluded due to inability to cover costs or other incurred expenses. Copy of daily trip itinerary is attached. Copies of all hotel accommodations are attached. Completed overnight field trip room assignment form is completed and attached. Supervision plan for overnight stay is completed and attached. Completed chaperone approval form is attached. All Parent Consent/Liability Waiver/Medical Release Forms have been collected. All documentation remains on the trip with the attending field trip sponsor and/or principal/designee. This is required for all clubs, organizations, band, chorus, educational and extracurricular trips excluding middle and high school designated sports. Sponsor has discussed chaperone responsibilities for an overnight field trip and supervision procedures with the school principal/designee. The Supervisor of Transportation received the request for Field Trip and Bus Request form at least 10 days prior to departure. sent to transportation returned to school The requested information must be completed and submitted with this form to the school principal. Principal/Designee Signature Page 2 of F006 REV 04/29/10 Submitted by Risk Management

12 CHAPERONE APPROVAL FORM SCHOOL YEAR SCHOOL NAME ATHLETIC TEAM/CLASS/CLUB/GROUP ON TRIP DATE OF FIELD TRIP/ATHLETIC EVENT FIELD TRIP SPONSOR/COACH DATE SUBMITTED TO VOLUNTEER COORDINATOR The following persons have been approved as chaperones for a trip that has been scheduled on the above date. These individuals have been verified by the school Volunteer Coordinator and have received a satisfactory background check to volunteer for school activities. Chaperone Name Phone Number Affiliation Code (P, T, S, N) Comment Code (D, O, NRF) Other Information AFFILIATION CODE P Parent T Teacher S Other Staff N Non-Parent COMMENT CODE D - Yes, approved for Daytime O - Yes, approved for Overnight NRF - No Level II screening record found for this individual Verified by School Volunteer Coordinator Approved by Principal/Designee Signature page of page 75 F007 10/15/10 Submitted by Risk Management 24

13 Overnight Room Assignment Form The following persons have been approved as chaperones for a trip that has been scheduled. These persons have been verified by the school Volunteer Coordinator and have received Level II clearance. Teacher/Coach: Chaperone: Teacher/Coach: Chaperone: Teacher/Coach: Chaperone: Teacher/Coach: Chaperone: Student(s) Student(s) Student(s) Student(s) Room # Assignment Room # Assignment Room # Assignment Room # Assignment Signature of Principal/Designee F008 10/15/10 Submitted by Risk Management