4531-E.2.3
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FIELD TRIP EXHIBIT
FIELD TRIP EXHIBIT
EXTENDED FIELD TRIP ● HEALTH INFORMATION
EXTENDED FIELD TRIP ● HEALTH INFORMATION
1.
Does the student have any allergies (including allergies to medication) Yes No
If so, please explain:
2.
Do you have concerns about your child walking strenuously
for long distances if required to do so on this extended field trip’? Yes No
If so, please explain:
3. Does your child have, or ever had, seizure disorders? Yes No
If so. please explain:
4. Please explain below any dietary restrictions for your child.
5.
Does your child have motion sickness? Yes No
If so. will it require use of medication on this extended field trip? Yes No
If “Yes,” please contact the school nurse at once so appropriate and timely arrangements may be made with you for the proper handling and administration of your child’s medication during the extended field trip.
6. Please explain any concerns you have about potential homesickness or sleep problems your child may experience on this extended field trip:
7. Date of child’s last tetanus immunization …………………………………………………….
8. Please explain any medical condition or situation pertaining to your child we should be aware of during the time of this extended field trip:
9. Please attach any additional information you wish the school to be informed about conceming your child and this extended field trip.
………………………………………………………. ………………………….
Signature of Parent/Legal Guardian Date
Adopted: May 21. 1997
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