Student MFVF Form

Student MFVF Form

This Student MFVF Form (Medical, Field Visit, and Volunteer/Facility Consent) collects student and guardian information, medical authorizations, consents for program participation, and acknowledgments of program policies. Completion and signature by the student if age 18 or by a parent/guardian if the student is a minor is required for participation in school-sponsored activities and to permit the school to respond to medical needs and emergencies.

Student Information

Date of Birth:    Student ID:    Grade / Program:

Primary Phone:    Email:

Parent / Guardian Information

Relationship:    Phone:    Email:

Emergency & Medical Information

Emergency Contact Name:    Relationship:    Phone:

Physician Phone:    Health Insurance Provider:    Policy / Group #:

Authorizations, Consents and Acknowledgments

Medical Authorization: I authorize authorized school personnel and its designated agents to provide or arrange for emergency medical treatment, including hospital care and anesthesia, for the student named above when I cannot be contacted. I agree to be financially responsible for such treatment and related transportation. This authorization is effective for the current academic year or until revoked in writing.

Release and Indemnity: I hereby release, indemnify and hold harmless the school, its governing body, employees, volunteers, chaperones, and agents from any and all liability, claims, demands, causes of action, and expenses arising out of or in connection with the student's participation in school activities and field visits, except for claims resulting solely from gross negligence or willful misconduct of the released parties. I agree to defend and indemnify the released parties against any claim made by third parties arising from my child's acts or omissions.

Administration of Medication: School staff may administer prescription or over-the-counter medication only when accompanied by written instructions from the parent/guardian and, where required, from the prescribing health care provider. I will provide medication in original labeled containers and instructions for administration, and I authorize staff to follow those instructions.

Transportation Consent: I consent to student transport by school-owned vehicles, contracted carriers, or volunteers for school-sponsored activities, including field visits. I understand that transportation arrangements may include public road travel and that the school will use reasonable measures to reduce risk.

Photo/Media Release: I grant the school and program organizers the right to photograph and record the student and to use such images and recordings for educational, promotional, and archival purposes without further notice or compensation, unless I check the box below to deny permission.

Privacy & Records: I authorize the release of relevant educational and health records to program staff and emergency responders as necessary for the safety and welfare of the student. The school will handle student records in accordance with applicable privacy standards.

Program Policies Acknowledgment

By signing below I acknowledge that I have read, understand, and agree to abide by applicable program rules, attendance requirements, code of conduct, and disciplinary procedures. I understand that failure to comply with program policies may result in removal from activities without refund of fees, if any.

Certification

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of material information may result in disciplinary action, withdrawal of privileges, or other remedies allowed by law or policy.

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