PARENT CONSENT/INDEMINITY FORM
FIELD WORK
(To be returned no later than date___1st August 2024___. Please note, your child/ward will be
permitted to participate in the proposed field work only if this consent form is signed and
received on or before the above-mentioned date.)
I have been informed of the trip to ___Shiv Nadar School, Noida __from 5th August to 6th
August, 2024. I voluntarily consent to my child going on and actively participating in this Field
work.
I am aware of this excursion, its objectives and the activities that my child might be
participating in. I have noted the details of transportation, accommodation arrangements (if
required) and the accompanying teachers. I also understand and acknowledge that there are
inherent risks associated with travel and stay (if required), which despite the due care taken in
planning and executing this programme may not be mitigated.
*(Provide information with details if the student has some medical concerns. Attach medical
certificate if required. Mark ‘N.A’ if not relevant).
Please give any other relevant information that you may feel is important.
By my signature, I voluntarily confirm satisfaction with the itinerary, arrangements and field
trip details shared with me.
Student Name & Grade :
Parent/Guardian name :
Relationship to Student :
Email of Parent 1 : Mobile #:
Email of Parent 2 : Mobile #:
Date : Signature of Parent
Contact information in case of an emergency
Name of contact person:
Relation with the child:
Address:
Email:
Mobile:
Landline (with city code): Signature
______________________________________________________________________________
_______
Health Declaration of student
Blood group of your ward :__________________
Any visual impairment? Yes/ No/ Occasionally
Hearing loss? Yes/ No/ Occasionally
Any heart related condition or epilepsy? Yes/ No
Does your child have any health-related condition that would affect active participation on the
proposed field trip?
______________________________________________________________________________
_____
Allergic to any medication? _______________________________________________________
Any recent injury or surgery or any other serious illness or ailment? Yes/ No
If yes, please give details______________________________________________________
Does your child have had any of the following or are you under medication for any of the
following conditions?
If yes, mention the health regime.
Allergies
________________________________________________________________
Asthma
________________________________________________________________ Influenza
________________________________________________________________
Diarrhoea
_______________________________________________________________
Infections (Malaria)(Dengue)
________________________________________________________________
Convulsions
________________________________________________________________
Joint pains
________________________________________________________________
Urinary infection/stone
________________________________________________________________
Menstrual issues
________________________________________________________________
Diabetes
________________________________________________________________
Hypertension
________________________________________________________________ Hepatitis
________________________________________________________________
Cardiac problems
_______________________________________________________________
Please mention any particular dietary requirements:
________________________________________________
Please give any other relevant information that you may feel is important.
Signature of the parent
