DEPARTMENT OF DEFENSE EDUCATIONAL ACTIVITY - EUROPE OFFICE OF THE PRINCIPAL PATCH ELEMENTARY SCHOOL UNIT 30401 APO AE 09107

STUDY TRIP PERMISSION FORM

Destination: Wilhelma Zoo Purpose of the Activity: To study animal classification and habitats. Sponsors of the study trip: Patch Elementary School Date of the Study Trip: April 30, 2013 Buses depart PES: 8:30 a.m. Buses depart zoo: 1:30 p.m. Meal Arrangements: Pack a lunch and snack. Entry Fee or other costs: 17.00 euro per student and 24.00 euro per adult. Special Clothing or materials needed: Please dress according to the weather for

the

day. All activities will be outdoors!

I give my student, _______________________________, permission to participate in the above named study trip.
I accept the responsibility for coming to the trip site to pick up my student if he/she is behaving in a disruptive, unacceptable or inappropriate manner or in the case of a medical emergency. In the event that my child is injured or becomes ill, necessitating immediate medical attention, examination or care, while participating in any activity associated with the Patch Elementary School Study Trip described above, I authorize the above named faculty sponsors to take my child to any U.S. Military Medical Treatment Facility or to any civilian hospital if deemed necessary by the above named individuals representing Patch Elementary School. I understand that the above named individual(s) of Patch Elementary School will make every effort possible to contact myself or my spouse. If neither I, nor my spouse can be contacted after reasonable attempts are made, I authorize the above named individual(s) to act in my behalf to have medical personnel examine my child. I authorize any and all emergency care necessary for treatment of injuries or illnesses involving immediate danger to the life or limbs of my child. I further authorize and release any physician or other qualified medical personnel to administer non-emergency care necessary to treat minor injuries or illnesses of my child. I authorize treatments to include suturing of superficial lacerations, treating colds, minor allergies, minor gastro-intestinal problems, splinting, casting of fractures or other treatments, not including major surgery or procedures involving substantial risks. I know of no special medical problems of which a treating practitioner should be aware except those listed in the REMARKS section below (known allergies are listed) REMARKS: __________________________________________________________________________

_____________________________ Parent/Sponsor Signature _____________________________ Date _____________________________ Home Telephone Number _____________________________ Emergency Contact Person

_____________________________ Printed Name of Sponsor _____________________________ Name of Spouse _____________________________ Duty Telephone _____________________________ Emergency Contact Telephone

The above consent is effective for the date(s) of the activity: ______________________________

STUDENT AGREEMENT

I agree to respect the rules or proper and appropriate behavior as required by the sponsor(s) of the activity. I understand that any violation of school rules or activities dealing with alcohol, drugs, smoking, or curfew will result in my parent/sponsor being notified to come to the activity site and take me home from the activity.

_________________________ Signature of Student _________________________ Date

_________________________ Printed Name of Student