Gates Chili Middle School

Parent/Legal Guardian Permission/Medical Form

 

As parent/legal guardian of                                                                          , I give permission for him/her to participate in a school sponsored field trip as described in the letter from the teacher. I understand all school policies, regulations and rules will be in effect and apply to my student for the duration of the trip. If my student violates any rule or refuses to follow directions given by an adult, I understand consequences may be assigned.

 

In case of emergency I can be reached at                                                            . If I cannot be reached I give permission to contact (name and number)                                . I understand every effort will be made to contact me, but if the school is unable to reach me, I give the school/supervising staff member permission to seek medical help for my student. I agree to release and hold blameless the Gates Chili School District and district personnel of any financial burden in the event of an injury or theft.

 

In the event a medical emergency occurs, I’ve provided the following information; Name                and                number                of                family                doctor:                                                                                                           List of current medical conditions, if any:                                                                                         

List of current medications, if any:                                                        (If your student needs to take mediations while on the trip you need to contact the school nurse to make arrangements.)

List of allergies, food restrictions, physical limitations and/or phobias, if any:

 

Medical Insurance Company and policy number (optional):                                                                                                                                                        Other comments or information that should be known:

 

REFUND POLICY: All payments are nonrefundable, and parent agrees to no refund even if the school cancels the student for academic or behavioral reasons before or during the trip. No refunds for invalid, incomplete or missing School Permission Forms.

 

DAMAGE: Parent agrees to accept responsibility for the actions of the above named student with regard to any damages incurred at any point during the trip, either to property, self, or to another individual, and further agrees to make restitution in full for any and all such damages within seven (7) days of the return of this trip.

	Please indicate the T-shirt size your student will need.
Note: T-shirts are ADULT SIZE ONLY!            Extra Small                   Small                          Medium                       Large            X-Large                 2X-Large                      3X-Large

 

Parent whose signature appears below acknowledges and agrees to all policies set forth.

 

 

Parent or Guardian Name:                                                                                                                  

 

Parent or Guardian Signature:                                                                                                            

 

Date: