Student Winter Retreat Permission Form

Student Winter Retreat Permission Form

Event Details

Program/Organizer:

Departure date:   Return date:

Departure time:   Return time:

Student Information

Date of Birth:   Student ID:

Parent / Guardian Information

Relationship to Student:

Emergency & Medical Information

Relationship:   Phone:

Permission to administer over-the-counter medications (acetaminophen, ibuprofen, antacids, antihistamines) according to dosing instructions:   Any medication to be administered by staff will be listed above and supplied in original labeled packaging.

Consent, Release & Medical Authorization

I, the undersigned parent or legal guardian, authorize the named student to participate in the Student Winter Retreat described above. I acknowledge that participation may involve inherent risks, including but not limited to travel, winter weather, snow-related activities, physical activities, and group living. I voluntarily assume all such risks associated with participation.

In the event of illness or injury, if reasonable attempts to contact the undersigned have been unsuccessful, I authorize the program's representatives to obtain and consent to any emergency medical care deemed necessary by licensed medical personnel. I agree to be responsible for costs of such care and transportation. I authorize release of medical information to appropriate personnel for treatment and continuity of care.

Further, on behalf of myself and the student named herein, I release, waive, discharge and covenant not to sue the organization, its trustees, employees, volunteers, chaperones, and agents for any liability arising from or related to the student's participation, except for willful misconduct or gross negligence.

I understand that by signing this form I authorize program staff to provide routine first aid and to seek emergency medical treatment for the student. This authorization shall remain in effect for the duration of the event unless revoked in writing.

Consent to medical treatment:

Photo/video release (I authorize the use of my child's image for promotional or educational materials):

Transportation consent (I authorize my child to be transported by the methods indicated above):

Conduct, Discipline & Removal

Students are expected to comply with established rules and directions of staff and chaperones. Possession or use of illegal substances, weapons, or other conduct that endangers others will result in immediate removal from the event at the parent's expense. I understand that I am responsible for arranging and paying for my child's transportation home if removed for disciplinary or medical reasons.

I acknowledge that failure to disclose relevant medical or behavioral information may result in my child's exclusion from certain activities and that the program may require parent/guardian removal in such cases.

Financial & Refund Terms

Participation fee is due prior to departure. Deposit amounts and final payment deadlines are binding. Fees are non-refundable except as described here: refunds will be issued only for documented medical withdrawal or event cancellation. Additional charges for emergency transportation, medical care, or property damage caused by the student will be billed to the parent/guardian.

I acknowledge that payment is my responsibility and that I have read and accept the financial terms above.

Acknowledgment

By signing below I certify that I am the parent or legal guardian of the named student and that the information provided on this form is true and complete to the best of my knowledge. I have read and understand the provisions of this form, including the assumption of risk, release and indemnity provisions, medical authorization and financial obligations. I understand that this form remains effective for the duration of the event unless revoked in writing.

I agree to the terms and conditions set forth in this permission form:

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