Student Registration Form printable pdf download

REQUIRED FOR SOUND TO SEA PARTICIPATION

Student Registration Form

Student:___________________________________ School:____________________________

I give permission for ____________________ to participate in the Trinity Sound to Sea Environmental Education

Program held at Trinity Center located in Pine Knoll Shores, North Carolina. I understand that the students will be

housed at the center from ___________ to ____________ and participate in educational activities as an extension of

the classroom studies.

Should my child sustain or incur any accident or illness while attending Trinity Sound to Sea Environmental

Education Program, I hereby authorize the Director, or his agent, to perform reasonable Good Samaritan actions or

execute any documents, including any necessary releases, which might be required by any medical facility to

perform any emergency care in my behalf. In the event that a child has an illness or accident during the program

which requires a visit to the doctor or hospital, the existing family or school policies will represent the primary

insurance coverage.

I understand that my child will engage in outdoor activities that could involve risk of injury and that by allowing

my child to participate, I assume all responsibility for injuries resulting from my child’s unsafe and/or inattentive

behavior or failure to follow instructions from group leaders of the activity.

I understand that the director or school leaders may dismiss my child from the Sound to Sea Program if, in their

opinions, his or her conduct is not in the best interest of the entire group. I also understand that I am responsible for

transporting my child in the case of a discipline or medical problem where the school leaders deem it necessary for

the student to return home.

I further agree that in consideration of my child attending Trinity Sound to Sea Environmental Education

program, I will hold the said Trinity Center harmless from any action by me or my child on account of any injury or

damage sustained or suffered by my child while attending Sound to Sea. I hereby waive any right of legal action

against Sound to Sea, Trinity Center or the Episcopal Diocese of East Carolina.

do/

do not (please check one) give permission for images and audio of my child, captured during Sound to

Sea activities through video, photo and digital camera, to be used solely for the purposes of Trinity Center and

Sound to Sea promotional materials and publications, and waive any rights of compensation or ownership thereto.

Signature______________________Relationship_______________Date____________

Insurance Information:

This section to be completed by a parent or guardian.

Signature

Is your student covered by a health or accident insurance policy? Yes___ No___

If "yes," list policy type (school or other)__________________________________________

Required

Address of Insured (Student)____________________________________________________

City ___________________ State _______ Zip Code _____________

Name and Address of Employer/Employee that provides coverage:

Name ______________________________________________________________________

Address ____________________________________________________________________

City ___________________________ State ________ Zip Code _____________________

Name and Address of Insurance Company (Address to submit claims)

Name ______________________________________________________________________

Address __________________________City _________ State _____ Zip Code_________

Phone Number of Company (____) ____-______ Policy # ____________________________

Insurance Agent __________________________Address______________________________

City ___________________________ State ________ Zip Code ____________________

Student Registration Form

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