DRAFT
Parental Permission for: MadisonMetropolitanSchool District student, ______, ’s participation in the ______program/trip.
Student participation in the above-named program will include the following activities:
Transportation to and from ______(air and ground)
Transportation while in _____ (arranged by host school)
Lodging at ______while ______
[other activities]
Teachers/chaperones shall take precautions to keep students safe in the various activities during this program/trip. While remote, there are risks associated with the travel and the activities as well as the risk of exposure to diseases and bacteria present in a foreign setting.
There are additional risks to which the student may be exposed should he/she refuse to abide by the District policies and school rules and the laws of ______.
The undersigned student and parent(s) waive all claims against, release from liability and agree to indemnify, defend and hold harmless, Madison Metropolitan School District, its directors, officers, agents, teachers, leaders, and schools from: claims of whatever nature for any injury, (regardless of nature or cause, whether or not it results in death); any loss; illness; accident; delay; cost; and expense due to strikes, war weather, illness, quarantine, government restrictions or regulations, improper documentation or otherwise incurred as a result of the student’s participation in the _____ program/trip and activities.
It is agreed that MadisonMetropolitanSchool District, its employees and agents have full authority to take whatever action it deems necessary to safeguard the health, safety and well-being of the student. Such authority shall include authorization to secure medical treatment, including surgery, from local medical personnel and medical institutions or to send the participant home for such treatment. It is agreed that costs shall be paid by the student and/or parents or legal guardians or their insurers.
We confirm that student is in good health and may engage in the activities outlined above, and there is no problem either physical or psychological which may be of concern during travel. If student is currently taking medication for a medical or psychological concern, we confirm that the medication is effective, and does not cause side effects which would endanger the student or others while participating in this activity and that student will continue to take the medication as prescribed by his/her medical provider during this program, as is indicated in the information provided on the medical form.
It is agreed and understood that failure to abide by the program standards, as explained on the foregoing page, to obey local laws, or to follow rules may mean termination of the student’s participation in the program/trip. Student or parent or legal guardian shall cover all resultant expenses to return the student home. Parent/guardian shall travel to pick up the student unless they grant permission for the student to be sent home alone.
We certify that we have read, understand, and agree to the above conditions for participation. We understand participation in the activity(ies) is voluntary and hereby freely consent to participation by______(student’s name).
______
Student signature (date)Parent/legal guardian (date)