The Hawaii SA 1 form is a document used by parents or legal guardians to grant permission for their child to participate in school-sponsored activities that involve overnight or off-island travel. This form ensures that all necessary information is collected, including medical insurance details and transportation arrangements. To complete the process, fill out the form and submit it by the specified deadline.
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The Hawaii SA 1 form plays a crucial role in ensuring that students can participate in various school-related activities, especially those that involve overnight or off-island travel. This form serves as a parent or legal guardian's authorization, granting permission for their child to engage in specific events organized by the school or associated organizations. It requires essential details such as the activity name, school, organization, location, and the teacher or advisor overseeing the trip. Additionally, the form outlines the costs associated with the trip, including transportation, entrance fees, and any other expenses, providing a clear financial overview for parents. Parents are also asked to confirm their child's medical insurance coverage and whether they can drive or ride in a vehicle driven by an adult. This comprehensive document not only facilitates parental consent but also ensures that teachers are aware of students' absences from class, emphasizing the importance of making up missed work. Overall, the Hawaii SA 1 form is a vital tool that balances student participation in enriching experiences with the necessary safeguards and responsibilities of both parents and schools.
STATE OF HAWAII
DEPARTMENT OF EDUCATION
Distribution for overnight or off-island travel:
Original - Chaperone; 1 copy each to principal & parent
Parent/Legal Guardian Authorization for
Student Participation and Travel
This completed form and payment (if applicable) are due on or before:
_____________________________ to ____________________________________________________________.
(Date)
(Advisor/Teacher)
Permission is requested for your child to participate in the following:
Activity: _____________________________________
School: _____________________________________
Organization: ________________________________
Place: ______________________________________
Teacher/Advisor: _____________________________
Dates: ___________________ Times: ____________
Mode of Transportation: ______________________
a. Transportation... ($ __________ )
b. Entrance Fee..... ($ __________ )
c. Other Costs....... ($ __________ )
d. Total Cost.......... ($
__________0
)
Parental Permission
(To be completed by Parent/Legal Guardian)
Name of Student: _________________________________________________ Home Phone: _____________
Emergency Contact: ____________________________________________________ Phone: _____________
Check as appropriate:
(Please include relationship)
My son/daughter has permission to attend the above activity.
My son/daughter DOES NOT have permission to attend the above activity.
Medical Insurance Coverage
My child has medical coverage with: _______________________________________________________
(Name of plan, e.g., HMSA, Kaiser, Military, etc.)
My child is not covered by any medical insurance plan.
Private Vehicle Usage
My son/daughter may drive to the activity alone. (Form BO-4, “Application for Use of Private Vehicle to Transport Students” must be completed and attached to this form.)
My son/daughter may ride in a vehicle driven by an adult to the activity.
Igrant permission for the above named student to participate in the activity/activities listed above, and to travel by private or commercial car, bus, train, airplane, and other means of transportation as required.
Ifurther give permission to travel by the mode indicated above. I release the State from liability resulting from the use of other than school vehicles pursuant to HRS 286-181.
In the case of illness or injury to above named student, I hereby consent to and authorize such treatment as deemed necessary, and agree to pay for such medical and dental costs if incurred.
_____________________________________________________________
Print or Type Parent’s/Legal Guardian’s Name
__________________________
Parent’s/Legal Guardian’s Signature
Date
Teacher Acknowledgment for Student Travel (To be completed by subject teachers, if applicable)
Please sign below to acknowledge that the above student will be missing class because of the activity mentioned above. He/She understands that all class work shall be made up at YOUR convenience.
Home Room: _______________________________ Period 4: ___________________________________
Period 1: ___________________________________ Period 5: ___________________________________
Period 2: ___________________________________ Period 6: ___________________________________
Period 3: ___________________________________ Period 7: ___________________________________
Form SA-1, Rev. 9/09 RS 10-0308 (Rev. of RS 10-0167)
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