Office of Development and Properties at 601 S. Jefferson, Springfield, MO 65806 US - Model Permission Form - (Overnight and Multi-Day)
| Model Permission Form - (Overnight and Multi-Day) |
Note: this form may need to be signed twice by parents; once to request participation and again (notarized) if they wish to authorize emergency medical treatment. I/We, the parent(s)/guardian(s) of , request that (name of school/parish) allow my/our son/daughter to participate in the following (fifth) grade/youth group/etc) activity on date 1. (Place a description or destination of the activity here) 2. (Indicate the estimated time of return from the activity here) 3. (List any special conditions or information that parents need to know, if any. E.g. "Canoeing will be involved." "Cave exploring is part of this activity." "Sack lunches must be brought." Etc. [Special conditions: ] Chaperones will accompany the (teacher/leader's name). The educational purpose of this activity is: (describe). I/We understand the school/parish (will provide/will not provide) transportation. [If the school/parish/organization is providing transportation, the next sentences should read:] My/our son/daughter has permission to ride with a volunteer driver. I/We understand that no one under the age of 21 will be allowed to serve as a driver. [If the school/parish/organization is not providing transportation, the next sentences should read:] I/we understand that I/we are responsible for arranging my son's/daughter's transportation to the activity. I/We hereby release and hold (name of school/parish) harmless as well as any and all of its employees and volunteers from any and all liability for any and all harm arising to my/our son/daughter as a result of this trip. Date: Signed: Emergency Phone #: Signed: Emergency Phone #: I/We further authorize emergency medical treatment for my/our son/daughter should the need arise while on this trip. (List any medication or special medical condition that medical personnel may need to know in case of an emergency.) Signatures for this sections must be signed before a Notary Public. Medication: Medical condition(s): Date: Signed: Signed: *********************************** Subscribed and sworn to me this Day of 20 Signature My commission expires Notary Public