North allegheny school district

North Allegheny School District Overnight Trip Forms

NORTH ALLEGHENY SCHOOL DISTRICT

Medical Release Form

Student Name: School Date of trip Nov. 21-23, 2015

(Please PRINT clearly)

Trip Location (Please circle one): Smith Island/Port Isobel West

To Parents/Guardians and Students:

The sponsors of the trip to the Chesapeake Bay Foundation will make every effort to guard the health, safety, and welfare of the participants. Despite these efforts and the precautions taken, it can be anticipated that an emergency, sickness, or injury may affect students participating in the program.

The district carries liability insurance and beyond that neither the district nor any employee or agent with the district is or shall be liable for any injury, loss, damage, deviation, delay, or curtailment, however caused, or the consequences thereof which may occur during any part of the travel or study on the trip. The district therefore, requires that each program participant carry appropriate medical and liability insurance.
I have read the above paragraphs and do accept the statements set forth. Health and accident insurance for the duration of the program is available through:

Name of Company Type of Policy I.D. Number

Signature of Parent or Guardian Date

Signature of Student Date

Medical History
Please provide the following medical information as background to enable prompt and proper care in the event of illness or injury.
Known allergies to pharmaceuticals, insect bites, etc.



Will this student be taking medication while on the trip? Yes No

Medication Dosage

If necessary, may we administer an age appropriate dose of Tylenol or Ibuprofen?

Yes No

Special Needs: (diet, refrigeration of drugs, etc.)



Recent illnesses, etc.

Although they rarely occur, emergencies can arise whereby immediate action is required to preserve the health and welfare of the student. The agreement set forth below is designed to protect both students and chaperons in the event an emergency arises which requires immediate action parents would take if they were present.

The director of the trip will inform and consult with parents should an emergency situation arise.
PERMISSION FOR EMERGENCY TREATMENT
Since minors may not, as a rule, be administered an anesthetic or have surgery performed on them without the written consent of a parent or guardian, we are requesting that parents or guardians sign the following statement. This will prevent a dangerous delay in case an emergency arises whereby hospitalization and/or surgery may be required and it may be impossible to contact the parent or guardian immediately.
In the event of illness or injury to our son/daughter/ward:

born on we hereby authorize the directors of the Smith Island/Port Isobel field trip to obtain the services of a licensed practitioner and, where required, to give consent for each treatment as be necessary to the same extent and with the same effect as though we had given it ourselves.

Signature of Parent/Guardian Date

Student Name: School:

Emergency Telephone Numbers:

Name of Person to Contact:

Home Phone: Cell Phone: Work Phone:
Name of person to notify (if different from above):

Name Phone Number

Health insurance information (Necessary for ANY treatment):

Company Name Policy Identification Number

Student’s full name - please print Student’s social security number

PARENT/STUDENT RESPONSIBILITY FORM

CHESAPEAKE BAY FOUNDATION

November 21-23, 2015

SMITH ISLAND/PORT ISOBEL WEST

We are pleased that you are going on the Chesapeake Bay Foundation trip. What a wonderful opportunity to experience the marine environment first hand and to study about the people who rely on it for a living.

We’re sure you will have an enjoyable time, but we want you to know that your safety and the safety of the group are paramount to us. It is vital that you behave in a responsible manner at all times. Flagrant violation of the rules of the Chesapeake Bay Foundation or the rules set down by the chaperons will not be tolerated. Remember, you are representing North Allegheny School District. Should it become apparent that you cannot act in the proper manner; your parents will be called and asked to come and pick you up.
In signing this agreement, whether it be parent/guardian or student, you are agreeing to adhere to these guidelines. We hope that the appropriate behavior will be displayed by all.
Thank you and get ready for a GREAT experience.
Mr. Gamaché

Student Signature Date

Parent/Guardian Signature Date

NORTH ALLEGHENY SCHOOL DISTRICT
Parental Permission - Release Form

I/We, the undersigned parent(s)/guardian(s) hereby give my/our child,

permission to participate in the North Allegheny Middle School GOAL Program’s educational trip to The Chesapeake Bay Foundation Center on:

Smith Island, MD Port Isobel, VA

from November 21-23, 2015 according to the attached itinerary.

I/We hereby release and discharge the North Allegheny School District, its representatives and the GOAL Department Staff from any and all liability which may result from any cause whatsoever in connection with this trip to include transportation to and from all related activities. Further, as parent(s)/guardian(s), I/we have determined that my/our child is physically able to participate in these activities.
I/We also relieve and release the school district and chaperons from any and all liability which may result from the loss of, or damage to any luggage or any other item which my/our child may have in his/her possession during this trip.

Parent/Guardian Date

Parent/Guardian Date

Participant Information Sheet

Chesapeake Bay Foundation

Smith Island Environmental Education Center

Essential Items:
Clothing---Remember weather conditions on the Bay area always colder

and windier than on land. Be prepared!

A set of clothes to get wet and muddy; your entire body may get wet and muddy.

One pair of sneakers to get wet and muddy; sport sandals and aqua socks may be brought,

but are NOT useful for wading and getting muddy.

Waterproof boots may be substituted for sneakers during cold weather months, but are

not mandatory.

Rain gear----even if rain is not forecasted.

Hat, gloves, long underwear – preferably synthetic, not cotton or wool (spring , fall).

Wool socks (fall, spring).

Towel

Long sleeve shirt and pants, even in summer.

Heavy jacket, even in summer.

Notepad and pencil or pen.

Sleeping bag

Insect repellent (wipe-on, no spray), insect sting stick or cream, sunscreen, chapstick

Personal items (toothbrush, toiletries kit).

Brimmed hat

Bandana (for use as napkins and other activities).

Plastic bag for taking home wet clothes

Plain T-shirt to be painted on

Reusable water bottle

Optional Items

Camera with extra film

What to expect:

We are looking forward to your visit to Smith Island and Port Isobel. You will be seeing new things, meeting new people, and experiencing a different way of life for three days. Tylerton, the town on Smith Island where some of you will be staying, and the town of Tangier, VA are remote waterman communities inhabited by hardy, independent people. They may have a different lifestyle and values than you, and speak in an unfamiliar dialect. You will be guests on the island and we ask that you please act accordingly.

Environmental/Economic Study

Smith Island, MD

Sample Itinerary
Saturday, November 21

5:00 a.m. Leave by bus from the parking lot at Ingomar Middle School. The bus will be chartered from Butler Motor Transit.

12:00 p.m. Arrive in Crisfield, MD.

12:30 p.m. Ferry boat ride to Tylerton, Smith Island, MD or Port Isobel,

VA

1:00 p.m. Room assignments and introduction

Chesapeake Bay Foundation instructors (CBF)

5:00 p.m. Dinner

6:00 p.m. CBF program
Sunday, November 22

7:00 a.m. Wake up

8:00 a.m. Breakfast

9:00 a.m. CBF program

12:00 p.m. Lunch

1:00 p.m. CBF program

5:30 p.m. Dinner

6:30 p.m. CBF program

Monday, November 23

7:00 a.m. Wake up

8:00 a.m. Breakfast

9:00 a.m. CBF program

10:00 a.m. Leave Tylerton/Port Isobel

11:00 a.m. Leave Crisfield

7:30 p.m. Arrive at IMS

Smith Island I.O. Fall 2015 Page of