Field Trip Permits: ODYSSEY CHARTER SCHOOLS

ODYSSEY CHARTER SCHOOLS

FIELD TRIP PERMITS
Some field trips have limits on how many students may attend. Also, there are 'closing dates' that must be respected for teachers/advisors and health staff to prepare for a trip.

Please fill out the following form to be permitted to attend a field trip.
Student Name*

LAST NameFIRST Name
Choose the student's School*
Student Grade*
0=Kinder, 1=First grade to 12=12th grade, senior
Student ID Number*
Email to receive copy of this document
example@example.com
Choose if your student IS or IS NOT allowed to participate in this field trip*

I GIVE my permission to ALLOW my child to take part in this field tripI DO NOT wish my child to take part in the field trip

School Year*
Student Date of Birth*

MonthDayYear
Date
Student Gender*
Parent Phone Number*
Please enter a valid phone number.
Work Phone
Emergency Contact Name*

LAST NameFIRST Name
Emergency Contact Phone*
Teacher or Advisor*
Field Trip Destination*
Date(s) of Trip*

MonthDayYear
Use the 'start date' if this is overnight
I request that my child be allowed to participate in an authorized Odyssey Charter School Field Trip. I understand that my child will be chaperoned by a responsible adult while away from the school, who will take reasonable precautions to protect my child from harm and injury.

I understand that this is a supervised activity. In order to maintain order, students will be expected to comply with rules, standards, and instructions for student behavior. I waive and release all claims against Odyssey Charter School employees or their agents arising out my child's failure to remain under such supervision. If at any time my child's behavior is inconsistent with the standard for student behavior, his/her further participation may not be permitted.

In the event that my child is injured, becomes ill or involved in an accident while away, I understand that the chaperon will seek medical attention for my child, and the school will contact me as soon as possible, and that I will be financially responsible for medical treatment. I further agree to hold Odyssey Charter School, its employees, and agents harmless for any injury or illness caused by the negligence of persons other than employees or agents of Odyssey Charter Schools when such injury or illness occurs during the trip.

Student Health Information
Physician's Name*
Physician's Phone Number*
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Will your child be attending a field trip that extends beyond REGULAR school hours?*

YESNO
Does your student have any health conditions?*

YES: My child has a health conditionNo health conditions

If YES, please describe*
ex. Asthma, allergies, diabetes etc.
Please note any medical information which would be of help: (i.e., allergies, medications to avoid, current medications, etc.)

If your child requires medication or a health procedure that is not administered at school, the health office will need appropriate paperwork and Licensed Health Care Provider (LHCP) orders at least ten days prior to the trip. For questions, concerns, or to obtain the required forms, please contact your child's school health office.

If medical information/needs change during the school year, please contact the school nurse.

I, the parent or legal guardian of student listed above, authorize and direct Odyssey Charter School to obtain medical care for my child in the event such care is reasonably necessary. I understand that if possible, I will be contacted in the event my child requires medical attention. I grant to a licensed health care provider or accredited hospital permission to perform any reasonably necessary medical and/or surgical procedures that are essential for the treatment of my child and agree to be responsible for payment for such care. I release OCS, its employees and agents from any damages, liability, or loss resulting from the exercise of discretion in securing, in good faith, medical care for my child.
PLEASE CHOOSE ONE OF THE FOLLOWING:My child does NOT require any medication on the field trip.

My child requires an Inhaler or Epi Pen on the field trip
- Licensed Health Care Providers and CCF 643 Parent/Guardian Permission Form are required.
- Per NRS 392.425, permission is required from your Licensed Health care Provider for your student to carry and self administer these medications. (Obtain this form HS-96 in the Health Office)
My child requires diabetic care during the field trip
- Extended care orders are required for care outside of the school day.
- Licensed Health Care Provider orders and CCF 643 Parent/Guardian Permission Form are required.
My child requires medication or a health procedure during the field trip
- Medications must be in an appropriately labeled bottle from the pharmacy and less than 1 year old.
- Over the counter medications require a prescription from a Licensed Health Care Provider and must be in the original container. The prescription must include student's NAME, DOSE, TIME and indication for use.
- Licensed Health Care Provider orders and CCF 643 Parent/Guardian Permission Form are required.
FOR SECONDARY STUDENTS ONLY: My child is able to self administer his/her medication (except for controlled substances) during the field trip.
- Medications must be in appropriately labeled bottle with a written statement that the student may carry and self-administer the medication.

The Following medication/procedures are required: (only if necessary)

	Name	Dose	Time of dose	Other
Medicine 1
Medicine 2
Medicine 3

I acknowledge that I will provide Licensed Health Care Provider orders upon request

Photo/Video Permission
At times during a field trip, school personnel and/or news media may ask to interview, photograph, audiotape, film and/or videotape students. This material may be utilized in media that includes, but is not limited to, the following: newspaper articles, television coverage, websites, internal or external publications, newsletters, yearbook, video presentations, the Odyssey Charter School website and/or other publications related to school functions and activities.

Your signature on the form below authorizes the school to release your child's name, photograph, and/or audio/video/film reproduction. Once signed and dated, this shall remain in effect until the end of the current school year. At any time during the school year, however, you may revoke this permission for future use by notifying, in writing, the principal of your child's school.
Photo Release*

I GIVE PERMISSIONI DO NOT give permission
for Odyssey Charter School to release my child's name, photograph, and/or audio/video/film reproduction, broadcast or posting to the odysseyk12.org website, as described above.

Parent/Guardian Print*
Signature for participant: Give Permission
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date

Parent/Guardian Print*
Signature for Field Trip for non-participant
Date*

MonthDayYear
Date
Signature of Parent or Guardian*

Clear
Should be Empty:

ODYSSEY CHARTER SCHOOLS

Student Health Information

Photo/Video Permission