WAKE COUNTY PUBLIC SCHOOL SYSTEM

This consent form is to be signed only after understanding and agreeing to the information below.  IF THIS FORM IS NOT COMPLETED AND RETURNED PRIOR TO THE SCHOOL TRIP, THE STUDENT WILL NOT BE PERMITTED TO PARTICIPATE AND WILL REMAIN AT SCHOOL IN A SUPERVISED ACTIVITY.

Trip or Activity Planned

Apex High Band Trips/Activities for 2008-2009

Attached is an itinerary that includes the place or places to be visited, a daily schedule of activities, and the dates, times, and places of departure and return.

Purpose of Trip or Activity

Band Performances

Name of Teacher/Sponsor

Paul Rowe

School

Apex High

Method of Transportation

Activity Bus or Charter Bus

(WCPSS owned vehicle, charter bus/contract vehicle,*privately-owned vehicle)

*When privately-owned vehicles are used for transporting students, only the vehicle owner’s liability coverage is applicable to any vehicular accident. When students are transported by vehicles owned by Wake County Public School System, the school system vehicle liability coverage is applicable to any vehicular accident.

I understand school trips may be cancelled when necessary by the principal, superintendent, or board of education.  The school system cannot guarantee reimbursement when such cancellations occur.  Parents/guardians will be notified of any significant change in plans prior to the school trip.

I understand the following is expected of the student.

§         To follow instructions given by the teacher/chaperone.

§         Not to leave or separate from the group without appropriate authorization from a teacher/chaperone.

§         Comply with all school and district policies and rules of conduct.

In the event any of the above expectations or instructions are violated, I understand school officials reserve the right to remove the student from the trip and the student will be subject to school disciplinary consequences.

I represent that the student has insurance either through the school system’s student insurance program or through my own insurance carrier.

I request that the below-named student be allowed to participate in the trip planned and specifically consent to the student’s participation.

Name of Student

Parent/Guardian Signature

Date

Student Signature (Grades 6-12)

Date

If the trip includes water related activities (such as swimming, diving, boating, sailing, cruise ship travel, etc.) or participation on amusement park rides, I acknowledge the inherent risks in these activities and give my express permission for the student to participate in those activities.

I agree

do not agree

to the above special conditions.

Parent/Guardian Signature

Date

Parent/Legal Guardian Signature

Date

1^st Choice

2^nd Choice

Name:

Phone:

(Day)

(Night)

(Day)

(Night)

(Mobile)

(Mobile)

Family Physician:

Phone Number:

Date of last tetanus booster:

My child is allergic to:

Medication taken routinely:

Special health needs:

Name of insurance company:

Policy #:

This form must be kept with school officials at all times during the school trip.