Permission Slip

QUAKERTOWN COMMUNITY SCHOOL DISTRICT

STRAYER MIDDLE SCHOOL

 

PERMISSION SLIP & RELEASE

 

 

            I hereby consent to have my child, ___________________________________, participate in the Strayer Outdoor School education Program to be held the week of May 23-26. Students will either go May 23-May 24 or May 25-May 26.  I acknowledge that the trip will involve outdoor activities which could pose a risk of injury to my child.  In addition, I acknowledge Quakertown Community School District High School Juniors and Seniors will serve as camp counselors during this educational program.  The High School students that are to serve as counselors were selected by administrators at the Senior High School and at Strayer Middle School.  Those students were required to demonstrate that they were in good standing at the High School, with respect to academics and behavior, that they received the required clearances and successfully completed a training session defining the expectations of being an effective outdoor school counselor.

 

            I have reviewed this Permission and Release document and I consent to my child’s participation in the Strayer Outdoor Education Program.  As such, I hereby remise, release and forever discharge the Quakertown Community School District, its employees and agents, from any and all claims that may arise by my child’s participation in the program including any claims related to any injuries my child may suffer.  I understand that the program involves outdoor activities which are physical in nature and those activities could result in a personal injury.

 

My child, ______________________________, will in the Strayer Outdoor School Education Program. Please check one choice below

_____  Covered by School Insurance

 

_____  Covered by Family Medical Insurance

              Company name and Policy No. ____________________________________

OR

           

                         My child, ______________________________, will not participate in the Strayer Outdoor School Education Program.  I understand that my child is still expected to attend and participate in the regular school program on these days.

 

 

 

 

________________________________          ___________________________

Signature of Parent/Legal Guardian               Date

 

 

 

If Legal Guardian, provide proof of that Legal Guardianship.

 

My child will need to be administered medications while participating in the Outdoor School Education Program and I will execute the appropriate consent with respect to medication.  Please fill out enclosed medication form.

           

 

 For office use only

 

CHECK/MONEY ORDER #________  AMOUNT $__________ DATE RECEIVED_______

 

 

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