• Form IFCB-5

  • MEDICAL HISTORY PERMISSION AND RELEASE FORM

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  • PAST MEDICAL HISTORY


  • Food allergies? (Yes/No) . Please indicate what foods? .

  • PERMISSION FOR TREATMENT

  • My permission is granted for school supervisors to obtain necessary medical attention in case of sickness or injury of my student. I agree to release, indemnify, and hold harmless or reimburse the Cobb County School District (District), its Board of Education, and its members, employees, agents, representatives, successors or assignees, as well as its approvedadult trip supervisors (“District Indemnitees”) from and forever promise not to sue them on any and all claims, demands, rights, causes of action, liabilities, losses, damages, costs and expenses (including reasonable attorneys’ fees), whether known or unknown, that I, any other parent or guardian of the abovnamed student, the student or any other successor or assignee may have or may allege to have against the District Indemnitees or which may be brought against the District Indemnitees arising out of or in any manner relating to the student’s participationin the field trips, including but not limited any losses, damages or injuries or to the rendering of emergency medical procedures or treatment.

    7/1/14: School Health Services

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  • Form IFCB-3

  • "BLANKET" PERMISSION TO PARTICIPATE IN A SERIES OF SCHOOL-SPONSORED FIELD TRIPS

  • Student Information

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  • Family Insurance Information

  • Medical Information

  • Phone:

  • Does the student need to take medication?

  • No If yes, please identify allergy:

  • Release

    • I hereby request that (Student’s Name -PRINTED ABOVE ): participate in athletic team, band, orchestra, chorus, and/or any series of field trips related to one particular area of study or activity. I understand that transportation may or may not be provided by the Cobb County School District (District In the e vent transportation is not provided by the District, transportation will be the student’s responsibility.
    • Detailed trip information, including destination, date, time of departure, time of return, purpose, and supervision, should b e given in writing to the parents at least two (2) weeks prior to each trip in the series.
    • The Dist rict does have an indemnity plan pursuant to O.C.G.A. § 20 - 2 - 1090 that may or may not apply relative to the trip. Even if the plan covers some or all of the trip, the coverage amounts may not cover all injuries. I understand that as a parent I have the o ption of, and am encouraged to, purchase student insurance coverage either through the student accident insurance offered by the District or through my own insurance carrier.
    • If any emergency medical procedures or treatment are required during the trip, I consent to the trip supervisor(s) taking, arranging for or consenting to the procedures or treatment in his/her or their discretion.
    • I agree to release, indemnify, and hold harmless or reimburse the Cobb County School District (District), its Boar d of Education, and its members, employees, agents, representatives, successors or assignees, as well as its approved adult trip supervisors (“District Indemnitees”) from and forever promise not to sue them on any and all claims, demands, rights, causes o f action, liabilities, losses, damages, costs and expenses (including reasonable attorneys’ fees), whether known or unknown, that I, an y other parent or guardian of the above - named student, the student or any other successor or assignee may have or may all ege to have against the District Indemnitees or which may be brought against the District Indemnitees arising out of or in any manne r relating to the student’s participation in the field trips, including but not limited any losses, damages or injuries or t o the rendering of emergency medical procedures or treatment. NOTE: This form must be signed by student if the student is 18 years of age or older.
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  • IFCB-3

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  • Should be Empty: