PARENT/GUARDIAN PERMISSION SLIP FOR FIELD TRIP AND INDEMNITY AGREEMENT
Name of student
First Name
Last Name
Parent's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
As parent or guardian of the above named student, I give permission for my child to participate in the activity/field trip described as follows:
SM & SOZ Grades 6-9 Youth Night
Parish/School
ST MARY & SONS OF ZEBEDEE PARISHES
DATE OF ACTIVITY/TRIP
10-26-22; 11-9-22, 12-14-22, 1-11-23, 2-8-23, 3-8-23, 4-12-23
DESTINATION:
ST. MARY SCHOOL HALL/CHURCH & GROUNDS - LOMIRA
DESIGNATED SUPERVISOR:
LESA STAEHLER, DRE
CELL PHONE
920-979-4656
Transportation
N/A Families need to provide their own method of transportation to and from the event
DURATION OF ACTIVITY/DEPARTURE TIME
6:30 PM - 8:00 PM
RETURN TIME
N/A
MEDICAL INFORMATION AND RELEASE:In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior toany further treatment by the hospital or doctor.On field trips that occur during the length of the school day, any prescription medication already provided to the school will be carried andadministered by staff.
If you are unable to reach a parent/guardian at the above number, contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
PERTINENT MEDICAL CONDITIONS:
Check the box if you opt out of any image, photograph, or video of your child to be posted or published to social media by any chaperone or school personnel for this field trip.
FIELD TRIP CONSENT AND RELEASE:In consideration for my child/ward’s participation, I agree to reimburse and indemnify the parish/school for all reasonable legal and court feesincurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school Which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found legally liable for injuries sustained by child/ward, this paragraph will not apply. I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had. By entering my full name, I attest that this constitutes my legal electronic signature on this form.
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