Student Permission Slips

STUDENT PERMISSION SLIP AND MEDICAL AUTHORIZATION

School Name:    Phone:

Event / Activity Information

Date(s):    Location:

Departure Time:    Expected Return Time:

Student Information

Date of Birth:    Student ID:

Grade / Program:    Teacher / Advisor:

Student Cell/Phone:    Email:

Parent/Guardian & Emergency Contacts

Relationship:    Primary Phone:

Alternate Phone:    Email:

Medical Information & Authorization

Primary Physician:    Phone:

Health Insurance Provider:    Policy/ID #:

I authorize school personnel to administer the medications listed above in accordance with any written instructions provided:    I do not authorize medication administration:

Transportation

Transportation authorized (check all that apply):

School vehicle / school bus    Private vehicle (driven by school-approved volunteer or staff)

Walk / student walk home    Public or contracted transportation

Activity Risks, Rules & Releases

I understand that participation in the activity described above may involve inherent risks. I acknowledge that the school, its employees, volunteers, agents, and contractors will take reasonable precautions to ensure safety, but cannot guarantee against injury, loss, or other damage. By signing below I consent to my child’s participation and agree to the following terms.

Release and Indemnification: To the fullest extent permitted by law, I release and agree to indemnify and hold harmless the school, school district, officers, employees, agents, and volunteer chaperones from any claim, liability, loss, cost, or expense arising from my child's participation in this activity, except to the extent caused by the gross negligence or willful misconduct of the released parties.

Medical Treatment Authorization: If my child requires emergency medical treatment and I cannot be reached, I authorize the school and its agents to obtain medical care for my child, including transportation to medical facilities, and to consent to medical, surgical, or hospital care as reasonably necessary. I agree to be financially responsible for such care and any transportation.

Behavior and Discipline: I understand that my child is expected to follow all rules and directions of school staff and chaperones. Failure to comply with rules may result in suspension from the activity and the parent/guardian will be responsible for transportation home and any associated costs.

Activity-specific risks include:

Does this activity involve water or swimming? Yes No

If swimming, swimmer competency level:

Photography / Media Release

I consent to the school’s use of photographs, video, and audio recordings of my child taken during this activity for school-related purposes, including educational, promotional, and informational materials, without compensation:

I do NOT consent to the use of my child's image or recording:

Additional Instructions / Special Considerations

I certify that the information provided above is true and complete to the best of my knowledge and that I have legal authority to provide consent for the student named herein.

Sign Now