Parent'S Or Guardian'S Authorization For Pupil'S Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form (Page 2 of 2) in pdf

Parent'S Or Guardian'S Authorization For Pupil'S Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form Page 2

Approved Overnight Trip Health History and Release of Claims

Pg. 2

Please check the applicable space. If necessary a school nurse will contact you regarding the specific details of your

child.

_____ My child/ward does not need any medication administered while on the trip.

_____ I will provide the required documentation to the school nurse in order for my child/ward to self ‐

administer prescribed medication such as an epinephrine auto‐injector and/or asthma inhaler.

_____ My child carries an epinephrine auto‐injector.

_____ I will need the medication/s listed below administered to my child/ward by an approved licensed nurse

while on the trip. I understand my child/ward’s physician must complete the enclosed medication form.

___________________________________________________________________________

RELEASE OF CLAIMS

As a parent or guardian, I do hereby request and authorize the Principal to permit my child/ward to participate in

(activity) _________________________ (inclusive of customary trips in connection with such activity) during the school

year _____________. I understand that physcial hazards may be involved in the above described activity, and I do

hereby accept full responsibility for his/her acts while so engaged and in consideration of permission granted child/ward

to particpate in the Board of Education, and the faculty, employees and agents of said property real or personal caused

by, occurring in connection with, or arising from the above described school activity.

This healthy history is correct to the best of my knowledge and the student herein described has permission to engage in

all activities, unless otherwise noted by me. I herby authorize a school representative to stand in loco parentis for my

child/ward in the case of medical and/or dental emergencies. I give permission to the physician and or hospital selected

by a school representative to hospitalize, secure proper treatment for and to order medications, injections, aneshesia or

surgery. I realize that all efforts will be made to contact me before any action is taken. I further understand that I am

liable for all costs incurred and not covered by my insurance. I understand that this information will be shared with the

medical professional attending this overnight trip.

I, the undersigned, have read this release and understand all of its terms. I execute it voluntarily with full knowlede

of its significance.

Signaure of Parent/Guardian: _______________________________________ Date: ___________________________

Revised: 8/1/12

Parent'S Or Guardian'S Authorization For Pupil'S Participation In Board Of Education Approved Overnight Trip Health History And Release Of Claims Form Page 2

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