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Field Trip Permission Medical Authorization Form

Please complete the form below. Required fields marked with an asterisk *

This student my permission to participate in Cascade Heights Public Charter School (CHPCS) field trips and/or school authorized off campus activities for the 2021/2022 academic year.

These activities will provide an excellent educational experience for students.  Your permission and release from liability are required for your child to participate.  Please complete this form and return it to the school by September 9, 2021.

Types of transportation used may include: Parent Chaperones/Vehicles/Buses, and/or Public Transportation.


I further agree to release and hold harmless Cascade Heights Public Charter School and the North Clackamas School District, jointly and individually, and their officers, agents and employees from liability for any accident, injury, illness or death sustained by the above named student in connection with or while participating in field trips and/or school authorized off campus activities.


 In the event of any illness or injury I hereby consent to whatever x-ray, examination, anesthetic, medical, emergency, surgical or dental diagnosis or treatment and hospital care from a licensed dentist, physician and/or surgeon or emergency medical personnel as deemed necessary for the student’s safety and welfare.  It is understood that the resulting expenses will be the responsibility of the parent/guardian and not Cascade Heights Public Charter School and/or the North Clackamas School District.

If the student requires over the counter or prescription medication during the field trip the medication administration form must be completed and signed by the parent.   Physician signature is also required for prescription medication.  All medications must be delivered to the school in the original container with only the necessary number of doses included.


 It is understood that if there are additional fees for a specific field trip and/or authorized off campus activity these fees will be paid in advance of the scheduled activity date.


 It is important that all families understand that, should conditions in our country at the time of the trip be such that the school administration believes the trip will be unsafe in travel or destination, the trip will be cancelled.  The safety of our children is our first priority. 


If the student and/or student’s family cancels the student’s participation, there will be NO refund of fees or money.

Submission of this form constitutes your acceptance and consent of these terms and is considered equal to your signature.

Contact Information

Alternative Emergency Contact Person

Confirmation Email