TIVYHIGH SCHOOL

STUDENT PERMISSION, MEDICAL AND RELEASE FORM

I give my permission for ______to attend the __Senior Trip______to _____Lazy Hills Guest Ranch in Ingram_____. I understand that students must go and return in transportation provided by the school, or sponsor. On priorapproval of the sponsor, students may be released to their parents only. I have read the student’s pledge below and understand and support the same.

STUDENT’S PLEDGE: I, ______, pledge to uphold all school regulations and

the high standards of TivyHigh School. I understand that I am governed by the same rules on this trip as I

am at school. I also understand that possession of, having used or being under the influence of drugs and/or

alcohol, is prohibited and that the school’s authority to enforce policy includes the right to inspect personal

luggage, lodging accommodations, transportation vehicles, etc. if the need arises. I understand that any

infraction will be dealt with according to school policy and may result in my being sent home immediately

at my parent’s expense.

______

Date Student Signature Age Cell #

I verify that I have sufficient insurance coverage to take care of the cost of and accident that may occur

while my son or daughter is participating in a field trip. The policy number and other pertinent information

relating to my insurance program is:

Policy No.______

Name of Company______

Local Agent______
Other______

If, in the judgment of any representative of the school, my child needs immediate care and treatment as a

result of any injury or sickness, I do hereby request, authorize and consent to such care and treatment as

may be given to my child by any physician, nurse, hospital or school representative.

I hereby release the KerrvilleIndependentSchool District from any financial responsibility for any injury,

which might occur to my son or daughter during his/her participation on any field trip.

Every effort will be made to see that this student is well taken care of; however, since we must be prepared

for any situation, please fill in the following information:

Allergies:______

Any medical history we should know of: ______

Any special medication student must take: ______

When?______How often?______needed for what?______

Name of family doctor______

IN CASE OF EMERGENCY, where may we reach your family doctor? ______

Telephone Number

Please give name and phone number of nearest responsible party and someone we may contact in case first

party cannot be reached.

1. ______Phone: ______

2. ______Phone: ______

PARENT/GUARDIAN NAME: ______

CITY/STATE/ZIP: ______

HOME AREA CODE AND TELEPHONE: ______

BUSINESS TELEPHONE: ______PARENT OCCUPATION: ______

PARENT OR GUARDIAN SIGNATURE: ______

DATE: ______

RETURN BY TUESDAY, MAY 26TH