Spring Festival Trip — Medical & Permission Form

Student Information

Student first name *

Student middle name

Student last name *

Date of birth

Student ID number

Grade *

Medical History

List any allergies (food, drug, environmental) and medical conditions. If none, type "NONE". *

Physical & behavioral health notes for the nurse/chaperones (optional)

Dietary needs & food allergies for trip meal planning (optional)

Medication

My child may receive the following RASD standing-order medication(s) as needed during the trip. Leave all unchecked if your child should not receive any.

Will your child need additional medication(s) during trip hours? *

Emergency Contacts

Emergency Contact 1

Parent/guardian name *

Relationship to student

Phone number *

Alternate phone (optional)

Emergency Contact 2 (optional)

Contact name

Relationship to student

Phone number

Alternate phone (optional)

Proof of Insurance

Used only in the event of a medical emergency during the trip, and kept confidential.

Insurance carrier

Member ID

Group number

Insurance card — front photo *

JPG, PNG, HEIC, WebP, or PDF · max 15MB each

Insurance card — back photo *

JPG, PNG, HEIC, WebP, or PDF · max 15MB each

Parent/Guardian Consent & Signature

I certify that I am the parent or legal guardian of the student named on this form, and that the information provided is accurate and complete to the best of my knowledge.

I authorize the Riverside Area School District and its employees, agents, and designated chaperones to seek emergency medical treatment for my child in the event of illness or injury when I cannot be reached. Reasonable efforts will be made to contact me before obtaining medical care.

I agree to assume responsibility for any medical expenses incurred as a result of such treatment.

I understand that submitting this form electronically, together with my drawn signature below, constitutes my legal signature and has the same effect as a handwritten signature.

I have read and agree to the statements above, and I give permission for my child to attend this trip. *I grant permission for photos/video of my child taken on the trip to be used in school and music program materials.

Parent/guardian full legal name *

Date *

Draw your signature *

Submit

Email address to receive a copy of this form *

Please review all information above before submitting.