ELBA CITY SCHOOLS

PERSONAL LIABILITY AND MEDICAL RELEASE FORM

NAME _________________________PARENT/GUARDIAN___________________

ADDRESS__________________________ WORK PHONE ___________________

                     __________________________HOME PHONE____________________

I hereby agree to follow all rules and regulations established by the Elba City Board of Education concerning off-campus field trips.  I understand that all school rules and regulations are in force while traveling to and from as well as at said location.  I understand that I will be held liable for any damages to any property, be it personal, public, or commercial including but not limited to hotels, restaurants, vehicles, schools, etc. that result from my child’s personal actions.  I am aware that I must make up any and all missed assignments during this time frame.  I have read, and I understand the student handbook and my personal responsibilities.

I hereby agree to release the Elba City Board of Education, its representatives, agents, servants, and employees for any injuries which may occur to the above mentioned person at any time while attending this school-related activity.  This is to include travel to and from the activity, excepting only such injury or damage resulting from willful acts of such representatives, agents, servants and employees.

I do voluntarily authorize the Elba City Board of Education assistants or designees to administer and/or obtain routine or emergency diagnostic procedures and/or routine or emergency medical treatment for the above-named as deemed necessary in medical judgement.

I agree to indemnify and hold harmless the Elba City Board of Education and/or assistants and designees for any and all claims, demands, actions, rights of actions, and/or judgements by or on behalf of the above-named person arising from or on account of procedures and/or treatments rendered in good faith and according to accepted medical standards.

Having read and understood completely the Elba City Board of Education approved handbook concerning field trips, I do hereby agree to follow the procedures and practices described.  I fully understand that this is an educational activity and will, to the best of my ability, support the ideas and goals of this activity.

_________________________            ____________________________

Student’s Signature                                Parent/Guardian’s Signature

TRIP INFORMATION

·        Location of Field Trip _______________________________________________

·        Date(s)___________________________________________________________

·        Time of Departure__________________________________________________

·        Location of Departure_______________________________________________

·        Money Required____________________________________________________

·        Time of Arrival Back at School_________________________________________

·        Location of Arrival Back at School______________________________________

----------------------------------------------------------------------------------------------------------------

Medical Information

(please print)

·         Known Drug Allergies_______________________________________________

·         Last Tetanus Administration Received___________________________________

·         History of Heart Condition, Diabetes, Asthma, Epilepsy, or Rheumatic Fever____________________________________________________________

·         Medication Currently Taking__________________________________________

·         Any Physical Restrictions____________________________________________

·         Other Conditions___________________________________________________

·         Name of Hometown Family Physician and Telephone Number _______________

_________________________________________________________________

·         Closest Relative (name)______________________________________________

                    Phone (home) ______________________(work)__________________

·         Medical Insurance Information:

·         Company _________________________________________

·         Card Number_______________________________________

·         Parent’s Signature _________________________________________________