St. Thomas School

Student School Trip Permission, Assumption of Risks,

andWaiver and Release Form

Name of Student:
Permission Slips Due by: / Thur, 9/4 / Return to:Mollie Cogswell, Administrative Asst to Div Directors

Last Updated: 08/22/2012

In order to participate in the described field trip (“the trip”), each student must have a signed permission form from a parent/legal guardian, to include medical provider information, approval for administration of medication, consent for medical care, waiver and release of claims, and assumption of risks. Students who have not submitted a completed/signed form and required documents or deposits by the due date may not be able to participate in the trip. Field trips are essential elements of the STS program; however, they are not required.

Last Updated: 08/22/2012

Destination and Nature of Field Trip: / IslandWood - 4450 Blakely Ave NE, Bainbridge Island, WA 98110
Departure Date: / Monday, Sept. 8 / Time: / 9:20 am
Return Date: / Thursday, Sept. 11 / Time: / 2:30 pm
Method of Transportation: / Bus
Other pertinent Information: (description of activities, itinerary, clothing needs, snacks/lunch, itinerary, etc.)
Thank you in advance for your assistance in preparing your child for the Islandwood experience. Please return this form to Mollie Cogswell no later than Thursday, September 4
Please also refer to the Islandwood packet accompanying this form for details about what to pack and prepare for. We are also hosting an Islandwood parent meeting on Thursday, Sept 4th in the MS Plaza from 3:15 – 4:00 for those interested in learning more about the trip. Hope to see you there.
Thank you! Mr. Mechling

Please list conditions your child currently has that might require special management while on an extended field trip, and indicate instructions for special management while on the field trip (ex: Diabetes, seizures, heart or blood disease, asthma, reduced hearing or vision, etc.)

Treatment while on trip, if any:

List all allergies thatyour child has and anynecessary responses should an allergic reaction occur. If your child have a severe or life-threatening allergy, list it below and obtain an Allergy Action Plan form.

Allergies:
Treatment while on trip, if any:

Medication will only be given with prior written consent of the child’s parent/legal guardian. Parents must also complete all emergency forms and related permissions for over the counter (OTC) and prescription medications, including Tylenol and cough drops.

Pursuant to current state law, St. Thomas School is authorized to administer any medication only with prior written consent of the child's parent/legal guardian. Authorization is required for the School to administer cough drops, Tylenol, and any over-the-counter (OTC) and prescription medications. We define medication to mean all drugs, whether prescription or over-the-counter (including Tylenol, cough drops, and similar medicines).

All medication must be stored and dispensed by the school office. No medication will be given to children who do not have a consent form on file. Parents’ cooperation in this matter is greatly appreciated. The school agrees to supervise school-age children as they take their medication with a written statement from a health care provider indicating the child is capable of self-medication. However, the school cannot be responsible for seeing that students remember to take their medication.

Parents or guardians must supply the medication in the original container; the label must include the student’s name, physician’s name, the drug name, frequency, method of administration, dosage, duration, and any storage requirements.

Name / Relationship / Phone Number

In an emergency or life endangering situation, I authorize St. Thomas School to contact 911; have myself / my child transported to a medical facility for emergency care; to the performance of all examinations, diagnostic procedures and treatments deemed necessary by the attending physician until the parent (if a student), emergency contact, or family physician can be contacted. I will not hold St. Thomas School responsible for any expense incurred, and I agree to pay any expenses incurred in the care of myself/my child.

We understand that this activity involves risks, both known and unknown. I/We understand that trips of this type pose many risks, known and unknown and foreseeable and unforeseeable. Such risks include without limitation risks associated with air travel and other forms of transportation, risk of illness, injury (including death or disfigurement), loss and other damages from acts of God or Nature, reactions to foods, injuries occurring in the course of medical treatment and/or due to lack of medical treatment, acts of war or terrorism or other acts arising from conditions of social or political unrest, defects in product design, manufacture, or construction, or intentional (including criminal) or negligent acts. I/we freely and voluntarily agree to assume all risks that might arise in the course of or related to this trip other than the risk of gross negligence by St. Thomas School. In consideration for permitting our child to participate in this trip, in light of the above known and unknown risks, I/we hereby release St. Thomas School, together with its past, present, and future administrators, trustees, volunteers, employees, and other agents or representatives, from any and all liability, claims, or damages (including claims for costs and attorneys’ fees) arising out of or in any way connected to my/our child’s participation in this trip, even if caused solely by the negligence (other than the gross negligence) of St. Thomas School, its employees, volunteers, or other agents or representatives. This waiver and release expressly does not apply to acts of gross negligence by St. Thomas School, its employees or agents.
I/We personally agree to assume all risks, known or unknown (other than the risk of gross negligence by St. Thomas School) associated with my/our child’s participation in this trip, and further agree to defend, indemnify, and hold harmless St. Thomas School, its past, present, and future administrators, trustees, volunteers, employees, and other agents or representatives, against all liability, claims for damages arising out of this trip, including any claims made by others for personal injury or property damage allegedly caused by us or by my/our child, or any claims made on behalf of my/our child in light of his or her status as a minor.
By signing our names below:
WE GRANT PERMISSION FOR OUR CHILD (NAMED ABOVE) TO PARTICIPATE IN THIS FIELD TRIP. WE HAVE CAREFULLY REVIEWED THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. WE ARE AWARE THAT BY SIGNING THIS DOCUMENT WE ARE RELEASING LIABILITY, WAIVING CLAIMS, AND ASSUMING RISKS.
Signature of Parent / Date
Signature of Parent / Date

Last Updated: 08/22/2012