OFF CAMPUS ACTIVITY AND MEDICAL RELEASE FORM

Activity/Destination:�

Project is off campus, during the school day�� Leaving time:

Date: �� Return Time:�

Activity Supervisors:� Mr Bob Warren�� Cost to student:�

Transportation to location is BUS��____school vans ______� or car driven by_______________________ .

PLEASE PRINT:�

Student Name �� Grade Level �� Home Phone (�� ) ____________

Parent Name � �� Work Phone (�� ) ____________

Emergency Name (if other than parent) �� Emergency Phone (�� ) ____________________�� (Pager ___ Cellular ___ House ___ Work ___)

Doctor Name _____________________________�� Phone Number (�� ) ____________________

Insurance Company ___________ Policy # __________ ID# _______ Type (HMO, PPO, etc) ��

I request that my son/daughter be permitted to participate in the above activity. As a condition of being allowed to do so, I herby, release and discharge the school from any and all claims for personal injuries or property damage that my son/daughter may suffer as a result of participation in the activity described above, whether or not such injuries or damage are caused by the negligence (active or passive) of the school or it�s employees. Should it be necessary for my son/daughter to have medical treatment while participating in this trip, I herby give the school personnel permission to use their judgment in obtaining medical service and I give permission to the physician selected by the school personnel to render medical treatment deemed necessary and appropriate by the physician. I agree to relieve the school and other participating adults from any liability in connection with this request.� I realize that the school has no control over� possible terrorist attacks.

I understand that my insurance benefits that are effective have limited application.

**I understand that my son/daughter is participating in a Bishop Alemany High School event and will abide by all rules as stated in the Student-Parent Handbook. Failure to conform to all rules, including behavior and attire, could result in my being called to pick them up and maybe subject to other disciplinary action as stated in the Handbook.

Signature of Parent or Guardian �� Date ��

Print Name of Parent or Guardian ��

Street Address ��

City �� State �� Zip� ��