Student Permission Form for Spring Retreat

Student Permission Form for Spring Retreat

Retreat Details

Event:    Location:

Dates: From to    Departure time: Return time:

Student Information

Parent / Guardian Contact Information

Emergency Contact

Medical Information & Authorization

Primary Care Physician:

Health Insurance Provider: Policy #:

I authorize retreat staff to administer the student's prescribed medication according to written directions provided by the parent/guardian and the prescribing physician.

I authorize the administration of common over-the-counter medications (such as acetaminophen, ibuprofen, antihistamines) for minor ailments in accordance with established dosing guidelines unless otherwise noted above.

Transportation

I authorize transportation as indicated below (select all that apply):

School-operated vehicle (bus/vans)

Private vehicle driven by approved staff or volunteers

I consent to my child being transported by vetted volunteer drivers if necessary for retreat activities or emergencies.

Media Release

I grant permission for my child's image or likeness to be photographed, recorded, and used by the school or organizers for non-commercial educational or promotional purposes. I understand names will not be used without additional consent.

Acknowledgements, Assumption of Risk, and Release

I, as the parent or legal guardian of the student named above, authorize the student to participate in all activities associated with the Spring Retreat. I acknowledge that participation may involve inherent risks, including but not limited to travel risks, outdoor activity risks, and minor or serious injury. I voluntarily assume all risks associated with participation except to the extent caused by the gross negligence or willful misconduct of the school or its employees acting within the scope of their duties.

In consideration of allowing my child to participate, I hereby release, indemnify, and hold harmless the school, its board members, employees, volunteers, cooperating organizations, and agents from any and all liability, claims, demands, actions, or causes of action arising out of or related to any loss, damage, or injury (including death) to person or property, except where such loss or injury is the result of gross negligence or willful misconduct specifically attributable to the school or its employees.

I authorize school officials to secure emergency medical care for my child if deemed necessary and agree to be financially responsible for such treatment. If time permits, the school will attempt to contact the parent/guardian or emergency contact before treatment. If emergency contact is unavailable and treatment cannot be delayed, I authorize treatment as necessary to protect my child's health.

I understand that failure to follow behavioral expectations may result in disciplinary action, including possible removal from the retreat at my expense. I have reviewed the student code of conduct and retreat rules with my child.

I have read and understand the terms of this permission form, and I certify that the information provided is accurate to the best of my knowledge.

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