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Each fal , the Seventh Grade travels to Hancock Field Station near the town of Fossil innorth-central Oregon for a multi-day program of natural history instruction. The field station,operated by the Oregon Museum of Science and Industry in Portland, is one of the mostcomprehensive science camps in the nation. It is adjacent to the Clarno unit of the John DayFossil Beds National Monument and offers a rich program of paleontology and ecology—an idealcomplement to the Seventh Grade science curriculum. You can find out more about the historyof the Monument by visiting the National Park Service website at.
We wil depart St. Mary’s at 7:00 a.m. on Tuesday, September 10 and return to Medford around4:00 p.m. on Friday, September 13. Please plan to arrive at school by 6:30 a.m. on Tuesday the10th.
I have attached an OMSI Program Health and Medical Form
and a St. Mary’s permission slip.
Please take some time with your student to review the in the Student Forms section of our website. It provides an overview of thefacility and program as wel as a list of necessary equipment. Please return the medical formand the school permission slip to the front office no later than Friday, August 30.
Hancock Field Station is an exceptional educational resource and an experience your child won’tsoon forget. If you would like to assist as a chaperone or have any questions, please feel free tocal or email. We’re looking forward to a great trip!
Trip Information and Consent
Event: Seventh Grade trip
Destination: Hancock Field Station near Fossil, OR
Trip/Activity leader: Chris Johnson
Mode of transportation: Charter coach, rental vehicles
On-site activities: Natural history instruction, hiking, team-building activities
Date and time of departure: Tuesday, September 10 at 7 a.m.
Date and time of return to school: Friday, September 13 at approximately 4:00 p.m.
Please detach and return bottom section to school and retain the top.
Event: Seventh Grade trip
Student name ________________________________________________________________________
Parent home phone ______________________ Parent work/cell phone _________________________
Family physician ______________________________________ Phone ________________________
Please list any current medications, food allergies, drug allergies, or chronic medical conditions:
My child named above has my permission to participate in all aspects of the above-listed trip. In a medical emergency involving my son/daughter named above, I understand that every effort will be made to reach me for instructions. If, in the judgment of the trip leader or medical professional, delay in reaching me might jeopardize my child’s well-being, I hereby give my consent for the responsible leader or other St. Mary’s representative to authorize necessary hospitalization or treatment, including injections, anesthesia, surgery, and medication. As parent or guardian, I agree that my son/daughter is responsible for following all the rules and expectations of the trip named above. Behavior expectations are clearly outlined in the student Handbook. I also agree to be responsible for all debts not covered by St. Mary's School which are incurred by the student during the trip/activity, for all expenses not covered by insurance that are incurred as a result of any accident, illness, or medical emergency involving the student, and for all transportation costs to prematurely return the student to Medford, Oregon, should the student's continued participation jeopardize the safety or health of other participants. Signature of parent/guardian __________________________________________________ Date__________
816 Black Oak Drive Medford, OR 97504 773.7877 (p)
OMSI PROGRAM HEALTH AND MEDICAL FORM
All students and adults participating in OMSI Outdoor Science School programs must fill out this form completely. Return this form to
your teacher/group leader as early as possible. PLEASE PRINT CLEARLY IN BLUE OR BLACK INK. PARTICIPANT INFORMATION
HEALTH AND MEDICAL HISTORY
Please check if participant is subject to the following and include explanation.
List all current medications, time(s) taken, and for what condition(s):
List any allergies to medications, the reaction, and the severity:
List any past medical conditions, injuries, or medial illnesses that might affect the program, including any restrictions of activity for
Date of last tetanus inoculation. MUST BE WITHIN LAST 10 YEARS. (If your child was immunized before attending school, he or she
received a tetanus shot at age 5.) _____________________
Describe any behavior problems or habits that would be disruptive to group learning:
List any dietary restrictions (please be specific e.g. vegetarian, no pork, low salt, etc.):
List allergies to any foods, the reaction, the severity, and the amount tolerated (e.g. for lactose intolerance, can small portions of milk be
Do you authorize the group leader or Camp Manager to dispense over the counter drugs, such as Tylenol, Advil, or Benadryl
if you are not reachable to give immediate permission?
My child has my permission to participate in all sessions and field trip activities. I am this child’s parent or legal guardian, who is under the age of 18 years and who wants to participate in OMSI’s programs. In consideration of my child’s or ward’s participations in the programs, I hereby release, waive, and discharge OMSI, and all of its instructors, employees, officers, directors, agents, and volunteers from any and all liability to me, to my child or ward, and to all my legal representatives, assigns, heirs, and next of kin for damage and injury to my child or ward or to any person or property arising out of participation in the program, whether on OMSI’s premises or elsewhere. This agreement includes but is not limited to claims or demands on account of injury or damage caused or allegedly caused by the negligence of OMSI or any of the individuals listed above. Adult participant or parent/guardian signature: ___________________ Date: _____________________
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