|
St. Mary of Mt. Carmel School
425 Central Avenue
Long Prairie, MN 56347
August 31, 2011
At times during the school year, teachers may have an activity planned, which takes them and their students off the school premises. You will be informed specifically each time one of these activities occurs. Should there ever be an activity you do not want your child to participate in, either call or write a note to inform your child’s teacher or me. Examples of activities would be: visiting the nursing home to sing, etc.; visiting the senior center to sing; visiting the post office, bakery, court house, mini-courses, etc.; going to the public school for a Lyceum; participating in Track and Field Day at the track; and individual class trips taken at the end of the school year.
Brenda Gugglberger, Principal
PLEASE SIGN AND GIVE TO YOUR CONFERENCE INSTRUCTOR.
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
PARTICIPANT’S NAME________________________________________________________________
BIRTH DATE: ______________________________________
PARTICIPANT’S NAME________________________________________________________________
BIRTH DATE: ______________________________________
PARTICIPANT’S NAME________________________________________________________________
BIRTH DATE: ______________________________________
PARTICIPANT’S NAME________________________________________________________________
BIRTH DATE: ______________________________________
PARENT/GUARDIAN’S NAME: _________________________________________________________
HOME ADDRESS: ____________________________________________________________________________________
HOME PHONE: __________________________ BUSINESS/CELL PHONE: _____________________
I, _________________________________, grant permission for the above named children to participate in
(Parents’/Guardians’ Names)
any St. Mary of Mt. Carmel School/Church event at a location away from the St. Mary of Mt. Carmel School/Church site requiring transportation. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Mary of Mt. Carmel School/Church.
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor(s).
I agree on behalf of myself, my child(ren) named herein, successors, and assignees, to hold harmless and defend St. Mary of Mt. Carmel School/Church, its officers, directors and agents, and the St. Cloud Diocese, chaperones, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate St. Mary of Mt. Carmel School/Church, its officers, directors and agents, and the St. Cloud Diocese, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.
*Signature: ___________________________________________________ Date: _______________________________
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name & Relationship: _______________________________________________________________________________
Phone: __________________ Family Doctor: ________________________________ Phone:______________________
Family Health Plan Carrier: ________________________________________Policy #____________________________
OTHER MEDICAL TREATMENT: In the event it comes to the attention of St. Mary of Mt. Carmel School/Church, its officers, directors and agents, and the St. Cloud Diocese, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called.
*Signature: _________________________________________________ __ Date: ________________________
|
