6th grade: June 5th
7th grade: June 5th
To: Kellogg Middle School
I am the [choose appropriate option] Parent / Lawful Guardian of_________________________
(student's name). I grant permission for my child to participate in the field trip described below:
Destination: Silver Rapids
Date(s) of trip: Leaving Kellogg Middle School at 8:10 am
Purpose: Swimming/Fun
Scheduled time of return: We will return in time to catch the 3:10 bus.
Class or group attending: 6th grade, 7th grade
Transportation: Our own two legs! : )
Student’s special medical needs (if any):____________________________________________
Name and telephone number of doctor:__________________________________________
Emergency contact number(s) (parent or guardian) (as many as you have) _______________
____________________________________________________________________________
Authorized to Treat Minor: In the event that I cannot be reached in an emergency, I hereby
permit to call 911 and/or to contact a medical facility or physician selected by the School to
provide proper treatment to _________________________(student’s name) and that I will be responsible for all expenses arising in association with such treatment.
Prescription or Over the Counter Medication: I certify that I have on file in the School office, a current profile enlisting necessary medications that __________________________[student's name] must take.
Acknowledgment of Notification Regarding Risk: I hereby acknowledge that I have
been notified whether or not the activities involved in this field trip are considered to be of "high risk" to the participants.
Indemnity and Waiver of Claim: I, the undersigned, the [choose appropriate option] Parent /
Lawful Guardian of__________________________________ [student's name], hereby acknowledge that as a condition of the Student participating in the activity, agree to indemnify and hold harmless the School, its employees and volunteers, the Kellogg School District, its governing board, the individual members thereof, and all other district officers, agents and employees from any liability, lawsuit, cost, expense or claim of any type whatsoever (including legal fees) for any harm, injury or death arising out of the above mentioned activity.
Permission slips due 5/23
Download permission slip HERE or pickup in the main office at KMS