Field Trip Agreement Form

1 Field Trip Agreement

2 Emergency Medical Authorization

Student and Parent Field Trip Agreement
Student and Parent(s)/Guardian(s) agree to:
1. REPRESENT their individual school’s MESA program and their school and serve as official representatives of the statewide NM MESA, Inc., program. In addition, the student agrees to behave with the highest degree of professional behavior and to comply with all MESA policies as well as all school and district policies for the duration of all NM MESA, Inc., activities.
2. ACKNOWLEDGE that each student is assigned to an adult chaperone and a specific group for the duration of the field trip. It is critical to inform adult chaperones of student whereabouts and/or emergency situations.
3. FOLLOW AND CONSENT to individual and group instructions and/or rules for the duration of the field trip.
4. RELEASE NM MESA, INC., and New Mexico Tech from all liability.
5. ACCEPT THE CONSEQUENCES of improper behavior. NM MESA, Inc., has the authority to remove any student whose behavior is not exemplary and/or is hazardous to him/herself and others. NM MESA, Inc., demands a high standard of student behavior during participation in all NM MESA, Inc., events. MESA students that participate in illegal activities such as, but not limited to, possession or consumption of alcohol and/or drugs, theft, or vandalism, relinquish their current and future membership in NM MESA, Inc. Parents will assume all costs for damages to rooms, buses, facilities, return transportation home, etc. Any advance payments will be forfeited.
  Additional requirements in connection with any overnight field trip:
6. MAINTAIN polite and considerate behavior for the other guests in the facility (refrain from excessive noise, dangerous behavior, etc.), and adhere to all the rules of the facility.
7. BE IN YOUR ROOM by designated “Lights Out” time. Students are required to stay in their assigned room throughout the night, and be ready to begin the next day on time.
8. COMMUNICATE with your sponsor regarding the wake-up time and check-out procedures, breakfast arrangements, boarding bus, etc.
Student Signature*
Sign your name with mouse, digital pen, or on touchscreen device, using your finger.
Date Student Signature*
Date Format: MM slash DD slash YYYY
Parent/Guardian Signature*
Date P/G Signature*
Date Format: MM slash DD slash YYYY
Student's NM MESA Region*
If you're uncertain, please view the region pages on NM MESA's website.
- Central Inner Region
- North Region
- North Central Region
- Southeast Region
- Southwest Region
- West Region
Central Inner Region Schools*
If you do not see your school listed, select a different region above.
North Region Schools*
If you do not see your school listed, select a different region above.
North Central Region Schools*
If you do not see your school listed, select a different region above.
Southeast Region Schools*
If you do not see your school listed, select a different region above.
Southwest Region Schools*
If you do not see your school listed, select a different region above.
West Region Schools*
If you do not see your school listed, select a different region above.

Authorization for Emergency Medical Treatment
I am the parent or guardian of the student named below and give my authorization for NM MESA, Inc., to seek medical assistance for my child should the need arise. NM MESA, Inc., has my permission to take my son/daughter to a hospital and sign any authorization for emergency medical treatment. I understand that I am responsible for all medical costs, and waive any and all responsibility of NM MESA, Inc., and New Mexico Tech, for any medical and/or other costs associated with any NM MESA, Inc., function. Please notify your MESA advisor if any of the information below changes.
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Enter Email Confirm Email
Student Name*
First Last
Student Email
Enter Email Confirm Email
Parent/Guardian Signature*
Date of Signature*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Primary Phone*
Alternate Phone
Family Health Insurance Company
Policy Number
Emergency Point of Contact / Relationship
Person not living with you.
Contact's Phone
Student's School / Grade Level*
Student's Social Security No.
IMPORTANT: Please advise us of medical accommodations your son/daughter needs that might require specific attention or precautions.
Student Medical Conditions / Medication Student is Taking
For instance: asthma, dermatitis, etc. Each condition/medication on a new line
Student Known Allergies/Conditions
For instance: bee stings, penicillin, peanuts
Name
This field is for validation purposes and should be left unchanged.

Field Trip Agreement Form

Student and Parent Field Trip Agreement

Authorization for Emergency Medical Treatment

New Mexico MESA Inc.