Student PFA Form

STUDENT PFA FORM

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian Information (if student is a minor)

Relationship:    Home Phone:

Program / Activity Details

Location:    Start Date:    End Date:

Departure Time:    Return Time:

Transportation

School bus    Private vehicle (staff/volunteer)    Public transportation    Walking

Medical and Emergency Information

May school staff administer over-the-counter medications as needed? Yes No

Authorizations, Release, and Indemnity

I, the undersigned parent, guardian, or adult student, authorize the above-named student to participate in the described activity. I acknowledge that participation involves inherent risks, including but not limited to physical injury, illness, or property loss. In consideration for allowing participation, I grant the school, district, program, and their employees and volunteers permission to supervise and provide reasonable instruction and to take such measures as they deem necessary for the student's welfare.

I authorize program staff to obtain emergency medical treatment, including transport to a medical facility, and to consent to medical, dental, surgical, or hospital care as may be deemed necessary by licensed medical personnel when I cannot be reached. I agree to be financially responsible for all costs incurred for such treatment.

To the fullest extent permitted by law, I release and hold harmless the school, its governing board, employees, agents, and volunteers from any and all claims, liabilities, losses, or expenses arising out of or in connection with participation, except for gross negligence or willful misconduct. I further agree to indemnify the released parties for third-party claims arising from my child's actions during the activity.

By checking the box below I expressly indicate my agreement with the above authorizations and releases: I acknowledge and consent

Media Release

I authorize the school and program to take and use photos, video, or audio recordings of the student for educational, promotional, or archival purposes. I waive any right to inspect or approve the finished materials and release the institution from claims related to the use of such media.

Consent to media use    Do not consent

Code of Conduct & Acknowledgment

Participation requires adherence to all applicable school rules, codes of conduct, and directions from staff. Failure to comply may result in disciplinary action, including removal from the activity at the parent's expense. I understand that behavioral expectations are in effect for the duration of the activity and during travel to and from the activity.

I have read and agree to the code of conduct and understand the disciplinary consequences.

Additional Information

Certification

I certify that the information provided in this form is true and complete to the best of my knowledge. I acknowledge that falsification of medical or emergency information may jeopardize student safety and may result in removal from the activity.

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