Consent And Release From Liability Certificate Template (Page 5 of 5) in pdf

Consent And Release From Liability Certificate Template Page 5

CLAY COUNTY DISTRICT SCHOOLS

FIELD TRIP PERMISSION FORM - ELEMENTARY

By signing this form below I agree to the following:

1. My child, _________________________________has my permission to attend the field trip to

________________________________________on ______________ from ________ am/pm to

________ am/pm.

2. My child has permission to be transported by either school bus, charter bus or private vehicle.

3. In case of medical emergency the teacher has permission to seek medical care for my child and I

consent to any treatment necessary. I will be responsible for the medical bills.

4. I will pay the cost for the trip which is __________. I will not be entitled to a refund for any reason.

5. All physical conditions that my child suffers from are listed on the bottom of this form.

6. My child is healthy enough to participate in this activity without limitation.

7. In the event of motor vehicle accident I will file medical bills with my own insurance.

8. I release the School Board of Clay County from any liability for injury to my child which occurs on

this field trip.

9. My child will be under the supervision of school personnel or approved volunteers.

______________________________

Parent’s Signature/Date

Phone Number(s)

______________________________

Parent’s name printed

Child’s name printed

IMPORTANT: PAYMENT AND SIGNED PERMISSION SLIP MUST BE RETURNED TO THE TEACHER

BY _______________. YOUR CHILD WILL NOT BE ABLE TO PARTICIPATE IF THIS FORM IS NOT ON

FILE WITH THE SCHOOL.

PHYSICAL CONDITIONS: (PLEASE LIST)

Form C

_________________________________________________________________________________________

Consent And Release From Liability Certificate Template Page 5