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Student Group: Yr 10 IYA Bronze Assessment


(Student's Name) _____________________ (Homeroom) _____ has my permission to

participate on a field trip to Pak Chong, IYA Bronze Trekking Assessment

The students are travelling by Mini Van and will leave the school at
approximately 0745am
on Either: Monday 30th – Tuesday 31st May
Or Thursday 2nd June – Friday 3rd June 2011
and will return at approximately 1700hrs

The field trip will be under the supervision of the following NIST staff members:
Jason Reilly & Graham Wardle along with 6 additional NIST Staff

Student's emergency home or contact numbers:

Home _________________________ Mobile _________________________

Business ________________________ Mobile _________________________
Please respond to the following questions as appropriate:
1. Is the student on any personal medication?
Yes † No †
If yes – Detail the medication, dosage, time etc.

2. Does the student have any dietary restrictions?
Yes † No †
Details ______________________________________________________
3. Detail the swimming ability of your child
Non swimmer † Beginner † Moderate † Strong †
4. To the best of your knowledge, has your son/daughter been in contact with any
contagious or infectious diseases or suffered from anything in the last four weeks
that may be contagious or infectious? YES/NO
If YES, please give brief details _________________________________________

Student Commitment
I understand that as a student of NIST I am expected to abide by all NIST rules
regarding possession and use of tobacco products, alcohol and other non prescriptive
drugs as outlined in the Student Handbook. The consequence of not abiding by these
rules may involve me being sent home from the field trip at my family’s expense and/or
suspension. A worse case scenario may even involve recommended expulsion.

I will also display common courtesy in behaviour, language, attitude and manners on
this trip as well as adhere to any other guidelines required by the chaperones.

Student Name: ………………………………….. Signature: ……………………………

Year: ……………….. Date: ……………………….

Please Turn Over

Provided all due supervision by teachers is properly organised and carried out, I recognise
as parent/guardians of the above student that neither the school nor NIST staff members will
be held responsible for any accident or other unexpected event, nor for events arising from
the above student disobeying instructions.

I agree that if the student fails to follow the directions of the staff that I will arrange to collect
my child from the field trip / activity site at my own expense.

In addition, I give my permission for any necessary medical attention to be administered as

deemed necessary if I cannot be contacted beforehand.

Overnight Field Trips are governed by the Rules and Regulation of the Ministry of

PARENT / GUARDIAN'S NAME (PRINT) _____________________________________

(Signature) _________________________ (Date) _________________________

***Field Trips are a part of the school curriculum. All students are encouraged to participate.
Parents/students who have committed to a field trip will be invoiced for all non-refundable
costs associated with the trip in case of absence.***

The New International School of Thailand has a supplementary Personal Accident/ Medical
Cover Policy that applies to any official school trip that includes an over-night stay.
On these occasions (overnight trips) the Medical Cover is 160,000 baht for short term
emergency medical expenses, 200,000 Baht for death/disability and 50,000 baht for
emergency medical evacuation.
Parents are strongly advised to check whether these amounts are satisfactory for their
personal circumstances and may arrange additional insurance at their own cost if they so
desire. Any amounts in excess of the above must be paid for by the parents. The signing of
the consent form indicates that you as a parent understand that the school’s liability is
limited to the above sums.

with ________________________________________________(insurance company),

Policy No._____________________________________________________________

Policy renewal date._____________________________________________________

Return this completed form to: Khun Pare in the Secondary Office by:

FRIDAY 6th May 2011

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