NORTH JAKARTA INTERNATIONAL SCHOOL

OVER-NIGHT FIELD TRIP INFORMATION

___________________________________Name of Student

Please check one response in each section below:

Allergies

o My child has no known allergies.o My child is allergic to. _______________________

Medication

o My child is on no regular medication. o My child is on regular medication, and supervisors have my permission to

dispense medication to him/her. Please use the lines below to indicate the type of medicine, dosage, and other pertinent information.

Dietary Restrictions

o My child may not eat _________________________________

Medical Insurance

Please list your medical insurance company, policy number, and other pertinent information in the space below.

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__________________ __________________ __________Print Parent’s Name Parent’s Signature Date