Parental/guardian Consent Form printable pdf download

PARENTAL/GUARDIAN CONSENT FORM

Student Name:_________________________________________________________

Address:______________________________________________________________

Home telephone__________________________

Parents/Guardian Work Telephone _____________________ or_________________

PLEASE READ CAREFULLY

Name of Activity/Trip, including Location __________________________________________

Date of Activity/Trip_____________________________

Consent to Participate

I ______________________ being the parent/guardian of a student who is participating

(Name of Parent)

in the above described activity/trip, hereby give permission that my child named above may participate in

the activity/trip. I have read the attached memo which sets out the details of the activity/trip.

(A complete explanation of the trip should be given to the parents before the consent is signed .

The information should include: nature and purpose of the activity/trip; unusual factors ( special

risks);supervision to be provided; transportation arrangements; cost: etc.)

I hereby acknowledge that I have taken steps to inform myself as fully as possible concerning the details of

the activity/trip that my child will be taking and of the dangers facing participants of such activity/trip,

including the risk of physical injury.

Medical Information

I understand that there are potential risks associated with travel and the physical demands of the trip and I

hereby warrant that my child is physically fit to participate in the trip and all activities planned during the

activity/ trip.

Any medical information relevant to my child, including the names and dosages of any prescription or non-

prescription medications required by my child, is as follows: _____________________________

Assumption of Responsibility

I accept that it is my child’s responsibility to abide by the laws of the country and all places to which my

child travels and to obey all the rules set out for this activity/trip. I hereby agree that I will accept full

responsibility for any damage, injury or loss caused to persons or property arising out of the conduct of my

child.

I accept that my child must follow all rules and instructions required of activity/trip participants and I agree

that the supervisors of the activity/trip may require my child to return home if a breach of those rules occurs

and I agree to be responsible for and pay any and all costs that may arise.

I acknowledge that I am not relying in any way on any employee of the school division, or any volunteer

travelling with the students, for supervision or assistance of our child while actually engaged in the

activity/trip and under the direction of the personnel of the company organizing and running the excursion.

I also indemnify and save harmless the _____________ Board of Education from any and all actions,

causes of action, demands, expenses or losses whatsoever which they may bear as a result of my child’s

participation in this event by reason of damage to any and all property and any and all personal injuries,

including the death of others or my child.

____________________________________________________________________________________________________________

SSTA LEGAL SERVICES 2002

SSTA INSURANCE 2002

Parental/guardian Consent Form