Permission Form And Power Of Attorney printable pdf download

PERMISSION FORM AND POWER OF ATTORNEY

While the school endorses well-planned field trips as a valuable part of the extracurricular/instructional

programs, it can assume responsibility for the safety and welfare of the students while they are off-campus

only to the point of reasonable provision for their supervision. Field trips are an extension of regular school

programs; consequently, all rules and regulations governing student conduct are in effect.

I, the parent/guardian of

hereby grant permission for my child to participate

in the trip to___________________________________________________________________________.

I do hereby state, under oath, that there is accident and health insurance coverage for my child while

participating in said trip, and agree to maintain such coverage in full force and effect for the duration of the

trip. I agree to accept full financial responsibility for any and all costs incurred from such accident, injury,

or illness

(Policy name and #

In the event of accident or illness, if parent or legal guardian cannot be contacted immediately, I grant full

power of attorney to ____________________________________________________________________,

from the commencement to the termination of this trip:

(1)

To arrange for the transportation of my child, whether by ambulance or otherwise, to a

proper facility where emergency medical treatment would normally be administered,

including, but not limited to emergency room of a hospital, doctor’s office, or medical

clinic, and

(2)

To sign such releases as may be required in order to obtain such immediate medical or

surgical treatment as is required in the judgment of medical authorities at said facility.

I do further agree to indemnify, protect and hold harmless Illinois Mathematics and Science Academy, its

officers, Board members, supervisors, agents, servants, and employees who supervise students while on the

trip, from any claim or liability whatsoever, including, but not limited to, personal injury, property damage,

court costs, attorneys’ fees and interest, howsoever caused, as a result of said student participating in the

above described trip.

Parent/Guardian Signature

Date

Parent/Guardian Signature

Date

FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC

SUBSCRIBED AND SWORN TO ME THIS

Day Of _________________ , Year _____.

My Commission expires

Signature of Notary Public

Return by:

to:

Illinois Mathematics and Science Academy

1500 Sullivan Road, Aurora, IL 60506-1000

Permission Form And Power Of Attorney