Parent/guardian Permission Form printable pdf download

2500 W. 18

Avenue, Eugene, OR 97402

541-686-8655

PARENT/GUARDIAN PERMISSION FORM

______________________________________________________

(Field Trip)

I, (print your name) ____________________________, give permission for my son/daughter, (print name)

_________________, to participate in the class trip/activity. The teacher who will be working with my child is

____________________________. I understand that as in any school activity, my child may encounter risks to his/her

health and safety. Emergency care for my child may be provided and authorized by my child’s teacher during this

activity. Recognizing this, I give permission for my child to participate in the classroom event to:

__________________________________________________________________

I release the Pastors of Willamette Christian Center and the Administration of Willamette Christian School, its staff, all of

its Board, its officers and directors, and all other persons involved in Willamette Christian School from any liability

arising out of any accident, injury, or sickness that may happen ot my child. I will instruct my child to obey rules of the

trip/activity, and I understand that if my child disobeys those rules, my child’s teacher may refuse to allow him or her to

continue in the activity.

I understand that photographs and video may be taken of my child during this event and I release them to be used for

future school publications.

I also give permission for the provision of emergency medical care to my child, including blood transfusion and

anesthesia, should that, in the sole judgment of those administering such care, be necessary; and I release those

persons administering such care from any liability arising from providing the assistance. I agree to accept all financial

responsibility for the health care and emergency decisions deemed necessary including transportation by ambulance to

the nearest hospital.

Parent’s/Guardian’s signature: __________________________________________________ Date: _________________

Parent’s Name: ________________________________________________ Relationship: _________________________

Address: City, State, Zip: _____________________________________________________________________________

Home Phone: _____________________ Work Phone: ______________________ Mobile Phone: ___________________

Child’s Date of Birth: __________________________________________

Medical Insurance Carrier: _________________________________________ Policy #: ___________________________

Policy Holder’s Name: _____________________________________________ I.D. #: _____________________________

Student’s Physician: ______________________________________________ Phone: ____________________________

Student’s Dentist: ________________________________________________ Phone: ____________________________

List any prescription medications your child takes: ________________________________________________

Drug Name/Dosage Amount/Time/Reason: _____________________________________________________

Does your child have any medical conditions that we should be aware of? _____________________________

Parent/guardian Permission Form