Student Permission Packet

STUDENT PERMISSION PACKET

School / Program Identification

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian Information

Relationship to Student:    Primary Phone:    Email:

Emergency & Medical Information

Relationship:    Phone:

Physician Phone:    Health Insurance Provider:

Activity / Field Trip Details

Location / Destination:    Event Date:

Departure Time:    Return Time (approx):

School bus or chartered bus
Transported by school staff in private vehicle(s)
Transported by a volunteer parent/guardian driver
Walk to local destination (within walking distance)

Authorizations, Acknowledgments and Releases

Permission for Participation: I, Parent / Guardian Name: , hereby grant permission for my child, Student Name: , to participate in the activity described above and any incidental activities related thereto.

Consent for Treatment: If my child requires emergency medical treatment while participating in the activity and I cannot be reached, I authorize school officials or their agents to obtain or provide emergency medical care, including transportation to a medical facility and administration of necessary treatment as determined by a licensed healthcare professional.

Assumption of Risk and Waiver: I acknowledge that participation in the activity may involve inherent risks. On behalf of myself and my child, I voluntarily assume all risks associated with the activity, including travel, and agree to release, waive and discharge the school, its board, employees, volunteers, and agents from any and all liability for personal injury, property damage, or wrongful death arising from participation, except for such loss or damage resulting from the intentional misconduct or gross negligence of the released parties.

Indemnification: I agree to indemnify, defend and hold harmless the school and its representatives from any claim, demand, or cause of action, including reasonable attorney fees and costs, arising out of or related to my child's participation in the activity or my breach of this authorization.

I consent to the use of my child's photograph and likeness in school-produced materials and publications for educational and promotional purposes.
I do NOT consent to the use of my child's photograph or likeness; do not publish photos of my child.

Behavioral & Policy Acknowledgment

I acknowledge that my child is expected to comply with all applicable school rules, codes of conduct, and directives of supervising staff during the activity. I understand that failure to comply may result in disciplinary action and that I am responsible for the cost of transportation home if my child is dismissed for disciplinary reasons.

Additional Instructions, Special Provisions

Legal Certification

Authority to Consent: By signing below I represent and warrant that I am the parent or legal guardian of the student named in this form, or that I am an adult student aged eighteen (18) years or older. I certify that I have full authority to execute this permission and release and that all information provided on this form is true and complete to the best of my knowledge.

Acknowledgement: I have read and understand the foregoing statements, authorizations and releases and I voluntarily agree to their terms on behalf of myself and my child. I understand that this document is binding and affects legal rights.

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