Saturday, October 25, 2008
Field Trip Permission Slip
FAMILY FIELD TRIP & RELEASE FORM 2008-2009
I,______________________________________________________________________,
(Parent / Guardian Name)
parent/guardian of :
________________________________________________________________________
________________________________________________________________________
student(s) enrolled in OHDELA
hereby grant my permission for the above student(s), and following family members:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________Please list name(s) and relationship (s)
to attend the field trip:
The Classics,
(Name, Location, Date and Time of Trip)
WARNING: As with any field trip or adventure activity, there are significant elements of risk in various educational field trips. These risks include, but are not limited to: slips, trips, arrested falls, falls to the ground, using tools or engaging in authorized activities. As a result of these events, participants could encounter torn or strained muscles, fractures, cuts, scrapes, abrasions, bruises, permanent head and spinal injuries, and other injuries. I acknowledge that these risks exist and understand that although every attempt will be made to minimize such risks, certain inherent risks will always be present.
ASSUMPTION OF RESPONSIBILITY: I agree that my child/ children/ student(s)/ family member(s) is/ are mentally and physically capable of participating in OHDELA field trips and adventure activities, and that proper training and physical conditioning is necessary. I assume responsibility, and further release OHDELA, its staff and volunteers from all claims, judgments and liability for his/her actions and safety. I realize that his/her inappropriate actions may result in personal liability. I understand that my insurance carrier or I will be financially responsible for any injuries suffered or caused. My child/ children/ student(s) agree(s) to follow all rules, procedures and safety methods demonstrated. I understand that my child’s/ children’s/ student’(s)/ family member(s) privilege(s) to participate in this activity may be revoked, suspended, altered or modified if deemed necessary for his/her safety or that of other participants.
EMERGENCY MEDICAL AUTHORIZATION: I hereby authorize any medical treatment deemed necessary for my child/ children/ student(s) family member(s) as a result of activities on or related to OHDELA field trip activities. I have relied on my individual judgment and assessment of the risks involved. I acknowledge there have been no representations or warranties by OHDELA or by any of its agents or their employees. I acknowledge there is no OHDELA, nor any OHDELA Provider Liability Insurance to protect me or my child/ children/ student(s) / family members should any accident occur. Should anyone file any legal action against OHDELA or any of its agents or employees as a result of any injury my child may sustain as a result of, or related to, participation in field trip activities, I will indemnify and hold harmless OHDELA, its officers, agents and employees from any claim or liability of any kind, including attorney fees and court costs.
LIKENESS RELEASE: I give OHDELA and its affiliates, permission to use my, and all persons listed above, photo, image or likeness for the purpose of promoting OHDELA. The permission and authorization to use my photo, image and likeness is voluntary and without consideration of any kind, and is a result of my support for OHDELA’s educational program.
I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS
___________________________________________________________/___/________
Signature of Parent / Guardian Date
EMERGENCY CONTACT INFORMATION:
In case of Emergency, please contact:
________________________________________________________________________
Name Relationship Phone Number(s)
________________________________________________________________________