Emergency Field Trip Emergency Field Trip FormStudent Name First Middle Last SexGradeTeacherBirth Date (MM/DD/YYYY)Mailing address Street Address Apt # City State / Province / Region ZIP / Postal Code Home phoneSecond address is required if dual guardianship Street Address Apt # City State / Province / Region ZIP / Postal Code Home phoneIn case of injury, illness, or emergency, a LOCAL CONTACT would be:NameCell PhoneWork Phone Does your child have any health problems/allergies, etc.?Does your child take medicine regularly?Please note comments or special instructions regarding your child.Please note comments or special instructions regarding your child.In case of minor injury, we authorize the first aid be administered by a qualified person.FAMILY PHYSICIANPHONE # In case of an emergency and we cannot be reached, we authorize emergency treatment by our family doctor or nearest hospital.DRIVER FIELD TRIP INFORMATION AND INSURANCE INFORMATIONDriver 1Date of BirthPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Drivers License #Expiration DateSocial Security #Make, model, year of vehicle usedName of OwnerLicense Plate #Registration Exp. DateDriver 2Date of BirthPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Drivers License #Expiration DateSocial Security #Make, model, year of vehicle usedName of OwnerLicense Plate #Registration Exp. DateIf more than one vehicle is to be used, the afore-mentioned information must be provided for each vehicle. When using a privately-owned vehicle, the insurance is the limit of the insurance policy covering that specific vehicle. Insurance CompanyPolicy #Date of Policy ExpirationLiability Limits of Policy*Please note: The minimal required liability limit for privately-owned vehicles is $100,000/$300,000. Certification: I certify that the information given on this form is true and correct to the best of my knowledge. I understand that as a volunteer driver, I must be 21 years of age or older, posses a valid driver’s license, have proper and current license and vehicle registration, and have the required insurance coverage in effect on any vehicle used to transport students. I certify that the student and insurance information is correct. Parent SignatureDate Date Format: MM slash DD slash YYYY
