Field Trip Consent Form

Field Trip or Event

Departure Date

MonthDayYear

Departure Time

Hour Minutes

AM/PM Option

Departure Location

Field Trip Location(s)

Field Trip Dates and Locations

Field Trip Leader Name

First NameLast Name

Coach's Name

First NameLast Name

Dean/Supervisor Email

example@example.com

Trip Leader's Email

example@example.com

Coach's Email

example@example.com

Requester's Email

example@example.com

Student Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email (ECC issued email if applicable)

example@example.com

Emergency Contact

First NameLast Name

Relationship to Student

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I, the undersigned, have enrolled and intend to participate in the Elgin Community College sponsored field trip/event identified above. I acknowledge that I have read the trip plan details and voluntarily accept such risks normally incident to such activities. I have also read the “General Field Trip/Event Expectations” and agree to abide by the indicated directives. I hereby release, waive, discharge and agree to hold harmless Elgin Community College, and all its officers; trustees, servants, agents and employees (hereinafter referred to as “releasees”) free from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or relating to any loss, damage, or injury, including death that may be sustained by me, or to any property belonging to me, as a result of participating in this field trip/event. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death that may be sustained by me, or any loss or damage to property owned by me, as a result of my traveling to and/or staying at the destination described above. I further hereby agree to indemnify and hold harmless the releasees and each of them, from any loss, liability damage, or costs they may incur during my travels. It is my express intent that this Release shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative if I am deceased, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above-named releases.

I further agree that I am solely responsible for my own equipment, supplies, personal property and effects during the course of the field trip/event. I agree that all releasees above whom I have hereby held free from liability are only responsible for the general supervision of the logistical/educational aspects necessary to provide a safe and successful field trip/event and that they cannot and do not guarantee my personal safety.

I further agree that if I drive or provide my own motor vehicle for transportation to, during or from the program site, I am responsible for my own acts and for the safety and the security of my own vehicle. I accept full responsibility for the liability of myself and my passengers, and I understand that if I am a passenger in such a private vehicle, Elgin Community College, the College President, Board of Trustees and releasees are not in any way responsible for the safety of such transportation. In the event of any medical attention is needed, I authorize the leader(s) of the field trip/event or any qualified individual to administer the first aid necessary to maintain health until a physician may be reached or other medical assistance obtained. I further authorize any physician to administer such medical or surgical treatment diagnosed as necessary.

Elgin Community College sponsors field trips and special events for students as a means of providing a complementary and diverse learning environment. Field trip/event participants and leaders should conduct themselves in a professional and positive manner as representatives of Elgin Community College. All students must adhere to and are responsible for the Administrative Procedure 4.402: Student Code of Conduct and Administrative Procedure 3.401: Drug-Free Campus as part of their enrollment at Elgin Community College and participation on the field trip/event.

Follow instructor/staff directives, operating guidelines and instructions. Failure to comply with instructor/staff directives, engaging in prohibited conduct, or violation of any laws may result in disciplinary and/or legal action. Behavior that interferes with this learning opportunity is unacceptable and will result in student’s being discharged from the field trip/event (responsible for own transportation home), dropped from the class or expelled from the college.
Anyone with a history of medical conditions should consult with their physician prior to the field trip activity to be sure that they are in condition to make the trip or participate in the event. Any prescription medications required should be in the original container clearly indicating the patient and medication information. Be sure to take sufficient quantity for the duration of the event.
In the interest of communication and preparedness students should share their Field Trip/Event itinerary with their designated emergency contact person, particularly departure and arrival times.
The field trip/event lasts from the designated start time until its designated conclusion.
Participation is limited to students registered in the class/program/club sponsoring the field trip/event.
Field trips provide a unique learning opportunity; students should come with an open mind, a spirit of cooperation, and a sense of curiosity about the experience to make the most of this activity.
Students will be expected to not only abide by the laws of the State of Illinois and the USA, but also the laws of the locality they are visiting, in the event they are participating in international travel.

Heath Information – The information will be shared with the Trip Leader so that he/she is aware of the student’s needs. It is the student’s responsibility to talk with the Trip Leader if any aspect of the trip may cause concern as related to health conditions listed below. This information may also need to be shared with health professionals if an emergency situation arises.

Allergies or history of allergic reaction to foods:

Allergies or history of allergic reaction to medicines:

Diagnosed chronic medical conditions:

List any prescribed medications currently taking, including special instructions related to their use:

Accommodation needs - Please list any physical, emotional, and/or cognitive support needs the trip facilitator should be aware of to assist you in participating on this trip including specific modifications that would assist you. It is the student’s responsibility to talk with the Trip Leader about how their accommodations needs listed below will be met prior the trip.

Signature

Student Name

First NameLast Name

Date

MonthDayYear

Are you over 18 years of age?

Signature

Parent/Guardian Name

First NameLast Name

Field Trip Consent Form

Student Information

Event Consent

Additional Field Trip Event Expectations