Note: This form must be signed and returned with money for the field trip to the

school by October 1st if the student named below is to participate in the field trip.

Consent to Participate in Field Trip

and consent for treatment

I , the parent/legal guardian of give my

(Student’s name)

consent for my child to participate in the field trip described here:

Kindergarten will be going to the KC Pumpkin Patch on Monday October 12th . This will

be a half day field trip from 8:45 a.m.-10:45 a.m. for morning kindergarten and

12:45-2:45 p.m. for afternoon kindergarten. Please remember siblings are not allowed

and your child needs to wear gym shoes and socks. Weather permitting: A jacket may

be needed as well. This field trip is $5.00 and includes all activities at the pumpkin

patch and a pumpkin from the school yard pumpkin patch.

I further give my legal consent and authorize any representative of USD 231 to authorize emergency

medical treatment, including any necessary surgery or hospitalization, for my above-named child, for

any injury or illness of an emergency nature he/she incurred while participating in the field trip noted

above by any physician or dentist licensed in accordance with the provisions of the Kansas Healing

Arts Act, K.S.A. 65-2801, and any hospital.

I agree to pay and assume all responsibility for medical and hospital expenses and any

emergency services incurred on behalf of my child.

I acknowledge and agree USD 231 is not responsible for any medical, hospital expenses

and/or charges that are incurred in the medical treatment or hospitalization of my child. A photocopy

of this document shall have the same force and effect as the original. If my child requires emergency

medical treatment, I understand that school personnel will make a reasonable attempt to contact me

to seek my permission to authorize treatment. To facilitate contacting me, I agree to continue to

provide current work and home numbers to the school.

My student’s emergency contact during this field trip will be:

Name Phone #

Signature of Parent or Legal Guardian

Date

I would like to accompany the grou

group
roup as a chaperone, but
I realize I may have to drive on my own. (Car pooling with
other parents may be a great idea)
Destination: KC Pumpkin Patch
Date: October 12th, 2009
Time: 12:45-2:45 p.m.
Cost: $5.00 (Includes a pumpkin)
Meeting Place: Madison Elementary
What will your child need the day of the field trip?
Gym shoes & socks, a jacket (weather permitting),
and a smile! ☺

Please have permission form and money

turned in by:
October 1st
Destination: KC Pumpkin Patch
Date: October 12th, 2009
Time: 8:45-10:45 a.m.
Cost: $5.00 (Includes a pumpkin)
Meeting Place: Madison Elementary
What will your child need the day of the field trip?
Gym shoes & socks, a jacket (weather permitting),
and a smile! ☺

Please have permission form and money

turned in by:
October 1st