Student Girls Permission Form

STUDENT GIRLS PERMISSION FORM

Program / Activity Details

Activity/Program Name:

Sponsor / School:

Event Date(s):    Location:

Departure Time:    Return Time:

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian Information

Relationship:    Primary Phone:    Alternate Phone:

Emergency Contact(s)

Relationship:    Phone:

Relationship:    Phone:

Medical & Health Information

Primary Physician:    Phone:

Health Insurance Provider:    Policy/ID #:

Permissions and Authorizations

I hereby grant permission for my daughter named above to participate in the Activity/Program described on this form and I certify that the information I have provided is true and complete to the best of my knowledge.

I consent to my child's participation in the Activity/Program and related supervised activities.

I authorize my child to travel by the transportation methods provided for the event (school vehicle, contracted transportation, or parent/guardian-arranged transport), and I understand transportation arrangements may vary by activity.

I grant permission for photographs, video, or other media that include my child to be used by the school or sponsor for educational or promotional purposes, provided no identifying personal contact information is disclosed.

In the event of minor injury, I authorize staff or volunteers to administer first aid. In the case of serious illness or injury, I authorize emergency medical treatment, hospitalization, anesthesia, or surgery as deemed necessary by licensed medical personnel.

Release, Indemnity and Acknowledgment

By signing below, I acknowledge and agree that participation in the Activity/Program involves the potential for injury. I release, waive, discharge, and covenant not to sue the school, district, sponsoring organization, their officers, employees, agents and volunteers from liability for any and all claims, demands, losses or damages arising out of or related to any injury, illness or death sustained during participation, except for intentional misconduct or gross negligence. I agree to indemnify and hold harmless the released parties from any claims arising from my child's actions while participating in the Activity/Program.

I certify that I have disclosed all known medical conditions and that, to the best of my knowledge, my child is physically able to participate in the described activities. I understand that if my child demonstrates behavior that jeopardizes the safety of themselves or others, school personnel may remove the student from the Activity/Program and I will be responsible for any associated costs to return my child home.

Special Instructions / Additional Information

Acknowledgment of Age Status

Please indicate the student's legal age status:

Student is under 18 and this form is signed by a parent or guardian.   Student is 18 or older and may sign on their own behalf.

By signing above I certify under penalty of perjury that I am the parent or legal guardian of the student named on this form, or that I am the student and am legally authorized to sign for myself. I understand this document is a legal authorization and release and that signing it binds me to the terms herein.

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