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)

Attach any medical paperwork (optional): action plans, physician forms, anything needing a doctor's signature

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

Medication

These questions are just about the trip itself, which takes place outside the school day. Anything your child needs during the school day is still handled by the nurse.

Over-the-counter medication a chaperone may give

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

|none selected, so a chaperone would give nothing

Would your child need to carry and take any medication of their own during the trip? *

List only medication your child takes themselves, such as a rescue inhaler, an epinephrine auto-injector, insulin, and the like. Anything a staff member would have to administer, or that your child only takes during the school day, stays with the nurse.

Emergency Contacts

Emergency Contact 1

Parent/guardian name *

Relationship to student

Quick pick:

Or type any relationship in the box above, such as grandmother, aunt, neighbor or family friend.

Phone number *

Another number (optional)

Emergency Contact 2 (optional)

Contact name

Relationship to student

Quick pick:

Or type any relationship in the box above, such as grandmother, aunt, neighbor or family friend.

Phone number

Another number (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.