Field Trip and Medical Release

This release form will apply to any event that your child participates in during the 2025-2026 school year. To help us provide for the physical safety of your child, please fill out this field trip information and medical release form.

Student Name

First Name, Middle Name and Last Name

Birthdate

Date

Grade

Student Name

First name, Middle name and Last name

Birthdate

Date

Grade

Student Name

First name, Middle name and Last name

Birthdate

Date

Grade

Student Name

First name, Middle name and Last name

Birthdate

Date

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father/Guardian

First and Last Name

Father's Cell Phone Number

Please enter a valid phone number.

Father's Work Phone Number

Please enter a valid phone number.

Place of Employment

Mother/Guardian

First and Last Name

Mother's Cell Phone Number

Please enter a valid phone number.

Mother's Work Phone Number

Please enter a valid phone number.

Place of Employment

EMERGENCY CONTACTS (optional) if parents cannot be reached - PLEASE make sure these individuals are willing to accept this responsibility!

Name

Name of Emergency Contact

Relationship

Relationship of Emergency Contact to Student

Phone Number of Emergency Contact

Please enter a valid phone number.

Name

Name of Emergency Contact

Relationship

Relationship of Emergency Contact to Student

Phone Number of Emergency Contact

Please enter a valid phone number.

Are there allergies, medical conditions, or activity restrictions that we should be aware of? If so, please give details and which child it affects. Please note if your child needs to have Prescription Medication at school for example (epipens and inhalers

Name of Doctor

Address

Phone

Name of Dentist

Address

Phone

Hospital Preference

GENERAL RELEASE/HOLD HARMLESS AGREEMENT - As the parent/guardian of the above children, I understand the following:

Possibility of injury - Though activities will be carefully planned and supervised, the child above may incur personal injury or bodily damage while participating in such activities.
Necessity of permission - The student cannot participate in activities without releasing and holding harmless the school and staff.
General release and discharge - I, the undersigned, request that the school and the staff allow the child to participate in the activity and in consideration thereof agree to hereby release, and forever discharge the school, its staff or volunteers, claims, damages, costs, expenses, or damages of any kind growing out of or related to the activity.
Release for injury and damages - I acknowledge that this is a full and complete release for all injuries and damages which the above child may sustain as a result of participating in the activities.
Treatment for injury - I authorize the treatment of the student by a qualified and licensed medical doctor in the eventof a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, while said minor is participating in the activity, including transportation to and from the site. This authority is granted only after a reasonable attempt has been made to contact me, the parent/guardian.

Therefore, being the parent/guardian of the children named above, I give my permission for them to participate in and attend school activities and field trips during the '25-26 school year. I also understand the basic rules and discipline procedures of school activities and will help support these policies if contacted about my son/daughter.

Parent/Guardian Printed Name*

Parent/Guardian Signature*

Date*

Date

Mission Statement

Heritage Christian School exists to serve Christ by partnering with parents to provide biblically faithful, academically excellent education.

255 Hackberry Street - North Liberty, Iowa 52317 - Phone 319.626.4777 - www.hcs-nl.com

FIELD TRIP AND MEDICAL RELEASE 2025-2026