Comprehensive Permission and Releases Form
Category II and III Travel
The Columbia Public Schools 5th Grade Honors Choir will be taking a trip to Tan-Tar-A Resort Lake of the Ozarks, MO on October 7, 2017 for Choir Performance at MSBA Annual Conference.
This travel has been approved and endorsed by Columbia Public Schools District Administration.
Transportation will be provided by STA. The cost of the trip is $0.00.
PARENT/GUARDIAN INFORMATION
This information will be shared only with Columbia Public Schools (CPS) personnel, consulting and treating medical personnel and emergency personnel and/or other individuals working with CPS. Otherwise the information will remain confidential.
Student Name:___________________________ Date of Birth: __________ Age: ____
Height:______ Weight: ________ Gender:☐M ☐ F
Home Phone (___)________________ Family E-Mail: _____________________________________
Mailing Address:___________________________________________________________________
City: ________________ State: _____ Zip Code: ___________
Parent’s name: ________________________ Relationship to Student:_____________________
Work Phone:(___)____________________ Cell Phone:(___)__________________
Is it ok to text this phone? ☐YES ☐NO
Email (if different from above): _______________________________________________________
Parent’s name: ________________________ Relationship to Student: ____________________
Work Phone:(____)___________________ Cell Phone:(___)__________________
Is it ok to text this phone? ☐YES ☐NO
Email (if different from above): _______________________________________________________
If parents are divorced who has legal custody of child?_____________________________________
Are there any restrictions on information given to non-custodial parent? Yes No (Circle one.)
If yes, this information must be documented and attached to the Student Medical Information Form.
In the event of an emergency, if parent/legal guardian cannot be reached, who should be called?
Name: ____________________________________ Relationship to Student: __________________
Work Phone:(____)____________________ Cell Phone (____)________________
Is it ok to text this phone? ☐YES ☐NO
Email (if different from above): ______________________________________________________
Name: ____________________________________ Relationship to Student: __________________
Work Phone:(____)_____________________ Cell Phone:(____)_______________
Is it ok to text this phone? ☐YES ☐NO
Email (if different from above): ______________________________________________________
TRAVEL CONSENT
I hereby give my child/ward, ______________________________________________, student
number ___________________, permission to participate in the activities listed above.
____________________________________________ School will need to be
notified of my son’s/daughter’s excused absence, if trip takes place during the regular school year.
______________________________________________________ ___________________
(Parent or Guardian Signature) (Date)
MEDICAL CONSENT (Please Type or Print)
INSURANCE: Each participant is responsible for her/his own medical expenses. Medical insurance is recommended but not required.
Medical Insurance Company Name: ___________________________________________________
Phone:(____)________________ Policy Number: ________________________________________
Student’s Physician: ___________________________ Phone:(____)__________________
Student’s Dentist: _____________________________ Phone:(____)__________________
Participant Medical History
Travel can be strenuous depending on a student’s physical condition. The following information is important and will help us prevent health or medical problems before they occur.
Please provide an explanation and details to any yes responses below the questionnaire in the
Significant Medical History/Pre- Existing Conditions/Prescription Medicines section. Attach additional sheet(s) if necessary.
1. Any adverse reactions to medication? Please describe in the Significant Medical History/Pre-Existing Conditions/Prescription Medicines section below.
☐YES ☐NO
2. Is student currently taking any medication?
If yes, what type/dosage? What is the medication specifically for?_________________________
☐YES ☐NO
3. Any allergies to foods, medications, environmental factors? Please describe the allergic reaction
in the Significant Medical History/Pre-Existing Conditions/Prescription Medicines section below.
☐YES ☐NO
4. Any food/dietary restrictions? ☐YES ☐NO
5. Has student ever been stung by a bee? If yes, describe any allergic reactions. ☐YES ☐NO
6. Tetanus shot series up to date? ☐YES ☐NO
7. Any respiratory problems or asthma? (Students who use inhalers are required to carry them at all
times.) ☐YES ☐NO
8. Any heart defects or other heart problems? ☐YES ☐NO
9. Any history of seizures, convulsions, epilepsy or other medical disorders? ☐YES ☐NO
10. Any ankle/knee/hip or other joint problems? ☐YES ☐NO
11. Does student have diabetes? Describe Type: ____________________________________________ ☐ Y E S ☐ N O
12. If female, has student menstruated?
☐YES ☐NO
If no, does she know about it?
☐YES ☐NO
13. Has student consulted a mental health care professional in the past 2 years? Please explain. ☐YES ☐NO __________________________________________________________________
14. Does student have any other medical conditions that may preclude strenuous activities?
☐YES ☐NO
15. Does student wear glasses or contacts? ☐YES ☐NO
Significant Medical History/Pre-Existing Conditions/Prescription Medicines: Please list your student’s medical history including prescription medications, over the counter medications, hernias, ulcers, head injuries, cancer, arthritis, scoliosis, hearing/vision problems, learning differences, eating disorders or other illnesses (use extra page if necessary). In addition, please note if your student has any pre-existing medical conditions. If pre-existing medical conditions may be affected by participation in daily activities during our trip abroad, please have your doctor document these conditions and give approval or agree to discuss the condition with a Columbia Public Schools representative.
Date(s): _________________________________________
Condition(s):______________________________________________________________________
Implications/ Accommodations: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Parents/Legal Guardians (“parents”) of Minor Participant's – Medical Authorization and Permission
CPS staff is concerned about inappropriate use of both prescription and non-prescription medication by minors. Persons under 21 are not permitted to use medication without written permission from a parent, legal guardian, physician, or an authorized CPS staff person. Persons under 21 are not permitted to share medications under any circumstances.
We give permission for Columbia Public Schools Staff to administer the following over-the-counter
medications to our minor daughter/son:
PLEASE CHECK THOSE MEDICATIONS WE MAY PROVIDE YOUR MINOR DAUGHTER/SON:
☐Acetaminophen* ☐Ibuprofen* ☐Anti Diarrheal* ☐Stool Softener* ☐Benadryl* ☐Non-Medicated Cough Drops*
* Children under 12 years of age will be given age appropriate dosages of the above listed medications
I authorize CPS staff, contractors or other medical personnel to obtain or provide medical care for my child, to transport my child to a medical facility and to secure treatment (including but not limited to routine or emergency health care, hospitalization, injection, anesthesia or surgery) considered necessary for my child's health. I agree to pay all costs associated with that care and transportation
and agree to the release (to or by CPS) of any medical records necessary for treatment, referral, billing or insurance purposes.
Note to parents: except to the extent limited by this form, my child has permission to participate in all CPS activities. I authorize that all information on this form is accurate and complete and I have not withheld any information.
I, (Name of Parent/Guardian)________________________________________________________, (Relationship to Student)________________________________________________
of (Name of Student)___________________________________________________________, (Age)___________, (Student Number)_________________________________
DELEGATE CONDUCT PRACTICES AND PROCEDURES
1. The term “delegate” shall mean any student, attending district endorsed activities.
2. There shall be no defacing of public property. Any damages to any property or furnishing in the hotel rooms or building must be paid for by the individual or chapter responsible.
3. Delegates shall keep their adult advisors informed of their activities and whereabouts at all times.
4. Delegates should be prompt and prepared for all activities.
5. Delegates should be financially prepared for all possibilities.
6. No alcoholic beverages or narcotics in any form shall be possessed by delegates at any time, under any circumstances.
7. No smoking will be permitted.
8. No delegates shall leave designated areas (except for authorized activities) unless permission has been received from the adult advisor or chaperone.
9. Delegates are required to attend all general sessions and activities assigned, including workshops, competitive events, committee meetings, etc. for which they are registered unless engaged in some specific assignment taking place at the same time.
10. Delegates should be carrying or wearing appropriate identification at all times.
11. Appropriate dress is expected.
12. No boys in girls’ rooms, no girls in boys’ rooms
13. Curfew will be enforced. Curfew means delegates will be in assigned rooms.
14. Delegates will use digital cameras in an appropriate and respectful manner.
15. Delegates shall not engage in any lewd, indecent, sexual, or obscene act or expression.
16. Delegates shall not engage in verbal, physical, or sexual harassment, hazing, or name-calling. The use of slurs against any person on the basis of race, color, creed, national origin, ancestry, age, sex, sexual orientation, or disability is prohibited.
I approve the student named in this document to attend and travel to trip-related activities. I realize that violation of any rules can result in the immediate return of the student, at family’s/guardian’s expense, to his/her home community. It is the responsibility of the parent/guardian to meet the delegate at the airport, bus terminal, etc., should it be necessary to send the delegate home.
(Parent or Guardian Signature): __________________________________________________
(Date): ______________________
I have read and fully understand the Delegate Conduct Practices and Procedures and agree to comply with these conduct guidelines. I am aware of the consequences that will result from violation of any of the above guidelines.
(Student Signature): __________________________________________________________
(Date): ______________________
ACKNOWLEDGEMENT OF PERSONAL LIABILITY AND RELEASE OF LIABILITY
My child, ____________________________ [“Student”], has permission participate in Choir Performance at MSBA Annual Conference and any related activities or events (collectively referred to herein as “Choir Performance at MSBA Annual Conference.”
I acknowledge and I am aware of the risks inherent in Choir Performance at MSBA Annual Conference, which include but are not limited to risk of death or serious physical injury.
I assume any risk that may arise from Student’s transportation to, transportation from, and participation in Choir Performance at MSBA Annual Conference. I accept full responsibility for any and all medical expenses for any injuries that occur to Student as a result of participation in Choir Performance at MSBA Annual Conference.
I understand that the Columbia School District No. 93’s insurance does not cover damages arising from, or related to, injuries sustained by students during transportation to, transportation from, or participation in Choir Performance at MSBA Annual Conference.
I hereby waive any damages and/or harm resulting to Student as a result of participation
in Choir Performance at MSBA Annual Conference.
By signing this form, I knowingly, voluntarily, and for adequate consideration release and waive and further agree to indemnify and hold harmless the Columbia School District No. 93 (the “District”), the District’s insurers, and the District’s current and former members, employees, affiliates, successors, assigns, officers, agents, other insurers, servants, representatives, and all other entities affiliated with or related to the District from all claims, demands, suits, damages, actions, causes of action and liabilities arising in any manner out of, relating to, or connected with Student’s transportation to, transportation from, and participation in Choir Performance at MSBA Annual Conference, including but not limited to claims for any physical injuries, illnesses, death,
loss of property, or property damage sustained while participating in Choir Performance at MSBA Annual Conference, and including any injuries/illnesses/death sustained due to the sole negligence of the District or its employees, whether such negligence is present at the signing of this Release or takes place in the future. I understand that this Release is binding on my heirs, personal
representatives, next of kin, spouse and assigns.
Signature
I confirm that I have carefully read this Parental Consent and Release of Liability and agree to its terms knowingly and voluntarily. This Parental Consent and Release of Liability has been read and is understood by me. Both the parent/legal guardian and the student are required to sign this Parental Consent and Release of Liability, regardless of the student’s age.
______________________________ ______________________________ __________
Parent/Guardian Printed Name Signature Date
______________________________ ______________________________ __________
Student Printed Name Signature Date
-- CAUTION -- THIS IS A RELEASE -- PLEASE READ CAREFULLY –
