1. NORTH JAKARTA INTERNATIONAL SCHOOL
OVER-NIGHT FIELD TRIP INFORMATION
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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