INSTRUCTIONS TO STAFF/ADVISOR FOR USE OF

PERMISSION TO PARTICIPATE IN FIELD TRIP/ACTIVITY AND RELEASE FORM

(Staff Use Only)

1. The “Permission to Participate in Field Trip/Activity and Release’ form is initiated when a KS staff
member/advisor is planning field trips/activities that occur outside of the normal school day hours
(e.g. weekend overnights, neighbor island or out-of-state travel).

2. KS staff/advisors must complete Section I and give to parents/legal guardians for their signature.

a. Trip/Activity Planned: KS staff/advisor must describe in sufficient detail the place(s) to be

visited, dates, times and places of departure and return. Also, describe any known risks
associated with the planned activity in order to allow parents/legal guardians the opportunity
to make an informed decision. If staff/advisors are uncertain or would like assistance, staff
are urged to contact and consult with Legal.

b. Purpose of the Trip/Activity: KS staff/advisor should describe in sufficient detail the

purpose of the trip/activity.

c. Supervision of Students: KS staff/advisor should describe in sufficient detail the plan for
supervising students during the trip/activity, including the specific names of staff/volunteers
who will serve as chaperones and/or ration of staff/volunteers to students.

d. Transportation: KS staff/advisor should describe in sufficient detail the method of

transporting students, e.g. travel dates, name of air/bus carrier(s) and flight times.

e. Special Requirements: KS staff/advisor should describe in sufficient detail any special

requirements that apply to this trip/activity (e.g. because of rough ocean conditions, the
student is expected to wear a life jacket at all times). If more space is needed, to describe
behavioral expectations, staff may attach additional sheets.

3. The parent/legal guardian must complete and sign Section II and return to KS staff/advisors prior to
the scheduled field trip/activity.

4. This completed and signed form will be effective for the scheduled trip/activity and must be renewed
whenever there is a new trip/activity.
 KAMEHAMEHA SCHOOLS

Permission to Participate
In Field Trip/Activity and Release

PART ONE: To be completed by teacher/advisor

Student’s Name:

1. Trip/Activity planned:

2. Purpose of trip/activity:

3. Supervision of students:

4. Special requirements:

5. Transportation and Board Information

Date Time Carrier Flight #

Air

Ground

Lodging

Comments:
PART TWO: To be completed by parents/guardians:

6. Expectations and Instructions: I/we understand that my/our child is expected to, and my/our child
has been instructed by me/us to do exactly what he/she is instructed to do by the adult
staff/volunteer, and to comply with all special requirements, including those listed in #4 above.

7. Insurance and Release: I/we represent that the student has insurance through my/our own insurance
carrier and that any claims for accidental injuries must be filled out by me/us with my own insurance
carrier before presenting a claim to KS.

I/we request that the above-named student be allowed to participate in the trip/activity planned, and
I/we hereby specifically consent to his/her participation. If any emergency medical procedure or
treatment is required during the trip/activity, I/we consent to the trip/activity supervisor(s) taking,
arranging for or consenting to the procedure or treatment in his, her or their discretion.

In consideration for allowing my/our child to participate in the above-described field trip/activity and
on behalf of myself/ourselves, my/our personal representatives, my/our heirs, my/our assignees and
my/our child, I/we hereby waive and release any and all claims against KS and its Trustees, officers,
directors, agents, representatives, employees, in both their personal and professional capacities
(collectively also “KS”), for injuries, liabilities, losses or damages connected with or arising out of
my/our child’s participation in the trip/activity, my/our child’s transportation to or from the
trip/activity, or the rendering of emergency medical procedures or treatment, if any.

8. Cancellation Policy: I/we understand that all trips/activities are subject to the terms described in the
Notice Regarding KS’ Policy on Withdrawal of Travel Endorsement and Acknowledgement. I/we
am returning a signed acknowledgement of this policy if this trip involves off-island travel.

9. Indemnification Statement: In consideration for allowing my/our child to participate in the above-
described trip/activity, I/we agree to indemnify, defend, and forever hold harmless KS from and
against any and all claims, proceedings, injuries, liabilities, losses, damages and expenses including
reasonable attorneys fees and costs, relating to or arising our of the trip/activity, my/our child’s
transportation to or from the activity or the rendering of required medical procedures or treatment, if
any, to my/our child.

10. Parental Consent

I/we have read the information about the Kamehameha Schools’

(name of class/team/club)
plans for a field trip/activity as described in detail in this form. I/we have signed this permission
form only after understanding and considering the information contained in this form.

___________________________________________________
Father’s/Guardian’s Printed Name

___________________________________________________
Father’s/Guardian’s Signature Date

___________________________________________________
Mother’s/Guardian’s Printed Name

___________________________________________________
Mother’s/Guardian’s Signature Date

Address: ___________________________________________
___________________________________________

Telephone : Home: __________________/Work: _____________________ Cell: ____________________

 Permission for Initiation of Medical Care and Release

Activity: The Kamehameha Schools

(class/club/organization)

Inclusive dates are:

Itinerary includes:

Name of Student :

Student’s Medical Doctor: Phone:

Student’s Dentist: Phone:

Name of Medical Insurance Subscriber:

Our Medical Insurance Plan is: Number:

As the parents(s) or legal guardian(s) of the above named student (“my/our child”), I/we understand that the
ultimate responsibility for the medical treatment of my/our child rests with me/us and my/our family and
agree to the following:

Limited Emergency and Non-Emergency Medical Service: I/we understand that Kamehameha Schools
(“KS”) offers limited student emergency and non-emergency medical services. I/we hereby authorize such
emergency and non-emergency medical services for my/our child as may be deemed necessary or appropriate
by the KS Medical or Health Services Department or Site Staff at my child’s school, and that KS will make
reasonable attempts to notify me/us as soon as possible of injury or illness to my/our child.

Referral and Consultation: I/we further authorize KS to refer my/our child to, or consult with, such
physicians or facilities as KS deems necessary or appropriate. My/Our preference (which is not mandatory) in
the event of such referral or consultation is stated in this Form. I/we understand that any charges for such
referral and consultation shall be our sole responsibility.

Release: In consideration of my/our child’s enrollment in KS and on behalf of myself/ourselves, my/our

personal representatives, my/our heirs, my/our assignees and my/our child, I/we (a) waive and release any and
all claims against KS and its Trustees, officers, directors, agents, representatives and employees, in both their
personal and professional capacities (collectively also “KS”), for injuries, liabilities, losses or damages
connected with or arising our of the rendering of medical treatment to my/our child; and (b) we agree to
indemnify, defend and forever hold harmless KS from and against any and all claims, proceedings, injuries,
liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to the
rendering of medical treatment of my/our child.

NOTE: Specify on a separate sheet any special medical needs or problems such as allergies to foolds,
medicines, etc. Name medicine and dosage prescribed for asthma, allergies, etc.

Signed: _________________________________________________ Date _______________

Father or Legal Guardian

Signed: _________________________________________________ Date _______________

Mother or Legal Guardian
 KAMEHAMEHA SCHOOLS

Notice and Acknowledgment of KS’ Procedures Governing Student Behavior

While Traveling with Kamehameha Student Groups

1. Students who participate in school-related field trips/activities are expected to observe the policies
and procedures contained in the applicable campus Student and Parent Handbook or program
guidelines.

2. The rules of common courtesy must be followed in order to have harmonious relationships during the
trip:

• Students will show consideration for others regarding personal property and privacy, undue
noise during late hours, and the overall well-being of the group. They will exercise the
highest standard of conduct in order to reflect favorably upon themselves, their fellow
travelers and their school.

• Students should not use improper language or be excessively boisterous and rowdy.

3. Chaperones play an important role in providing security, guidance and coordination for a traveling
group.

• Students must realize that it is the duty of the chaperone to see that all school policies and
procedures are carried out and cooperate with them in this regard.

• Students are to be courteous to all chaperones. Disrespect or insubordination will not be

tolerated.

4. It is essential that students understand that rules regarding living arrangements while traveling must
be made so that the entire groups may be accommodated.

• Students will not leave hotel rooms in the evening without permission of the chaperone. No
student may travel away from the group alone at anytime.

• Students are to remain in their assigned rooms after 10:00 p.m.

• Students will be assigned rooms and must not change rooms unless arrangements are made
with the chaperone.

5. The use, distribution or possession of alcohol, marijuana or other unprescribed drug is prohibited.

6. Students are not permitted to smoke or gamble.

 7. Students are not permitted to drive a car at anytime without the permission of the chaperone.

8. Promptness on a trip is very important.

• Students are to attend all scheduled activities on time.

• If a student is late and a chaperone must stay behind to wait for him/her, the student shall pay
any additional transportation costs for both him/her and the chaperone to meet at the next
point on the itinerary.

9. Students may not borrow money from other students or chaperones. Travelers checks are
recommended.

10. Friends or relatives may pick up students prior to their scheduled departure date and be responsible
for their return only if arrangements have been made prior to departure on the trip. Requests must be
made in writing and signed by parents. It is recommended that parents/guardians complete the
Permission to Leave the Group form.

11. Students will attend all scheduled meals, practices, tours, scheduled programs and assigned
performances unless excused.

12. Illness is to be reported immediately to a chaperone.

13. Disregard for the rules by a student may result in disciplinary action such as a call to the parents or
guardian and an immediate return home at the student’s/parents’ expense. Serious infractions may
result in further disciplinary action up to and including release from KS.

Cut Here and Return Bottom Portion

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KAMEHAMEHA SCHOOLS

Acknowledgment and Receipt of KS’ Procedures Governing Student Behavior

While Traveling with Kamehameha Student Groups

I/We acknowledge that I/we have received a copy of KS’ Procedures Governing Student Behavior While Traveling
with Kamehameha Student Groups and agree to abide by them.

__________________________ __________________ and __________________________ __________________

Mother’s/Legal Guardian Signature Date Father’s/Legal Guardian Signature Date

_______________________________ ______________________
Student’s Signature Date
 Kamehameha Schools
Request for Medical Information and First Aid Kit
For KS Field Trip/Activities

The
(name of class, grade or organization)

has scheduled a field trip(s) on .

(day) (date)

Attached is a roster of those who will attend. Please advise me of any special medical conditions of the attendees. I
understand that this information is confidential to be used for medical emergency purposes only, that I must not
disclose this information unless there is a need to know, that I should store this list in a secure location and destroy
such information when no longer needed.

I understand that I need to bring a first aid kit with me during the field trip/activity and that staff from the Medical or
Health Services Department is available to instruct me about appropriate use of the contents.

I need a first aid kit for the trip/activity. I will make arrangements with the designated medical or
health services staff to pick one up the day before the field trip/activity.

I need a first aid kit for the school year for recurring field trips/activities of the class/club. I want to
make arrangements to use one for the school year.

I need training on how to use the contents of the first aid kit and will call the designated medical or
health services staff to set up an information session.

Name Extension
 KAMEHAMEHA SCHOOLS

Permission for Alternative Transportation

Name of Child _________________________________________________________________

School or Educational Site _______________________________________________________

Field Trip Name and Date ________________________________________________________

I/We understand that the standard transportation method for students at Kamehameha Schools is via a KS approved
school vehicle(s) from KS premises to the field trip site(s) and back to KS premises. I/We request permission to make
a change from this standard transportation method by the following method(s) [please check all that apply]:

_____I/We will transport my/our child and sign him/her in at the field trip/activity site.

_____ I/We have designated another adult to transport my/our child and sign him/her in at the field trip/activity site.

Name of responsible adult __________________________________________________

_____ I/We will transport my/our child and sign him/her out from the field trip/activity site.

_____ I/We have designated another adult to transport my/our child and sign him/her out from the field trip/activity
site.

Name of responsible adult __________________________________________________

In consideration for allowing me to deviate from KS’ scheduled method of transportation, and on behalf of
myself/ourselves, my/our personal representative, my/our heirs, my/our assignees and my/our child, I/We (a) waive
and release any and all claims against KS and its Trustees, officers, directors, agents, representatives and employees,
in both their personal and professional capacities (collectively also “KS”), for injuries, liabilities, losses or damages
connected with or arising our of my deviation from KS’ scheduled method of transportation for my/our child; and (b)
we agree to indemnify, defend and forever hold harmless, KS from and against any and all claims, proceedings,
injuries, liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to the
alternative transportation arrangements for my/our child.

___________________________________________________________ _____________________
Signature of Father/Legal Guardian Date

___________________________________________________________ _____________________
Signature of Mother/Legal Guardian Date
 KAMEHAMEHA SCHOOLS

Permission to Leave the Group

Name of Student _________________________________________________________ Grade ____________

Trip Name and Date _________________________________________________________________________

Date and Time of Separation

Date __________________________ Day of the Week _____________________

From _________________________am/pm to ___________________________am/pm.

Date and Times when child must remain with the group: ____________________________________________

Time and place for student to return with the group: ________________________________________________

Information about adult assuming responsibility for student (if not the parent(s)):

Name ___________________________________________ Phone: _______________________________

Address: __________________________________________________________________________________

Form of ID: ________________________________________________________________________________

Staff Member verifying identification: _____________________________ Date: ________________________

Adult acknowledging receipt of child: _____________________________ Date and time: _________________

I request permission for my child to leave the group with me/us/the above named adult (circle one) for the period
indicated above. I understand that reasonable care will be used to verify the identity of any adult taking temporary
physical custody of my child prior to the scheduled completion date/time of the field trip/activity. I understand that
my child may need to stay with the group during the period(s) indicated above, and I agree my child will be returned
to the group for said period(s). If for any reason my child is not returned to the group for said period(s), I assume
complete responsibility for all costs incurred in reuniting with the group later or missing the remainder of the trip, as
applicable.

In consideration for allowing my/our child to leave the group for the period indicated above, and on behalf of
myself/ourselves, my/our personal representative, my/our heirs, my/our assignees and my/our child, I/We (a) waive
and release any and all claims against KS and its Trustees, officers, directors, agents, representatives and employees,
in both their personal and professional capacities (collectively also “KS”), for injuries, liabilities, losses or damages
connected with or arising our of my deviation from KS’ scheduled method of transportation for my/our child; and (b)
we agree to indemnify, defend and forever hold harmless, KS from and against any and all claims, proceedings,
injuries, liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to my/our
child leaving the group.

___________________________________________________________ _____________________
Signature of Father/Legal Guardian Date

___________________________________________________________ _____________________
Signature of Mother/Legal Guardian Date