Liability Release Form
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1LIABILITY RELEASE FORM
Student Name
Home Telephone
Address
Zip Code
Date of Birth
Place of Birth
School
School Telephone
School Contact Person
Position
Parents/Guardians Full Names
Place/Times of Employment
Employment Telephone Numbers (
)
(
)
Person to contact in an emergency
Telephone
Address
Relationship
Physician
Telephone
RELEASE
I, a participant in the excursion to ________________________, on _____________________, 20_____,
sponsored by ________________________ and approved by ______________School District, agree to all the
following conditions:
The Program organizer(s), group chaperones _____________ School and the _____________School District shall
not be liable for any damages or loss to my person or property arising from my participation in this program.
The Program organizer(s) and/or group chaperones may make reasonable changes in the dates, destinations, or
itinerary for the mutual benefit and safety of group participants. In such event, they shall not be liable for any
delay, loss or damage resulting therefrom. In the event of any illness, accident, or incapacity incurred by me, the
group chaperone may consider my best interests in securing medical treatment, hospitalization, medication and/or
return transportation at my own expense.
Any and all claims, obligations, suits in any liabilities whatsoever against the organizer(s), chaperones, and/or the
School District are hereby waived and released.
I certify that I have read and understood this release and agree to abide by its provisions.
_________________________________
___________________
Student Signature
Date
_________________________________
___________________
Signature of Witness
Date
I certify that I am the parent or legal guardian of the student named above and that I have read the
foregoing release. I allow my child to participate in this trip. I agree to every part of this release and hereby
relinquish any claim that I may have against the program organizers, chaperones, and the School District, both on
my behalf and in my capacity as legal representative, while my child is a participant in this program.
______________________________
___________________
Parent Signature
Date
_________________________________
_____________________
Signature of Witness
Date
Page 36 – Liability Release Form
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