File Code:  IICA-F3

PARENTAL CONSENT, RELEAS FROM LIABILITY AND INDEMNITY AGREEMENT

(Teacher will file this form with the school office before the trip.)

 

I/We the undersigned parent(s) or guardian(s) of _________________________

                                                                                                (name of student)

a minor, do hereby consent to his/her participation in the following planned field trip to:  __________________________________________________________

_________________________________________________________________

On:  _____________________________________________________________

 

and furthermore I/we authorize any school teacher, administrator, and/or employee or official of the Town of Ipswich and/or Ipswich School Committee to authorize any medical treatment for said minor which may become necessary during the course of such participation and do forever RELEASE, acquit, discharge and covenant to indemnify and hold harmless the Town of Ipswich, a municipal corporation of the State of Massachusetts, and its successors, departments, officers, employees, servants, and agents, of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation on account of or in any way arising out of, directly or indirectly, any personal injuries, medical treatment or property damage which we/I may now or hereafter have as the parent(s) or guardian(s) of said minor, and also all claims or rights of action for damages which said minor has or hereafter may acquire, either before or after he/she reaches his/her majority, resulting or to result from said minor’s participation in the aforementioned activities or medical treatment authorized pursuant hereto.

 

 

__________________________                 ___________        ____________________

   Signature of Parent/Guardian                 Date                          Relationship

 

__________________________                 ___________

      Signature of Student                                       Date 

 

THIS FORM MAY NOT BE ALTERED.

(This portion to be retained by parent/guardian.)

TRIP INFORMATION

 

The _________________________________ class has arranged for an approved trip to

 

__________________________ on _______________________________________ .

 

Time Leaving:  _______ A.M. _______ P.M.  Time Returning:  _______ A.M. _______ P.M.

 

Teacher in charge of trip:  _____________________________________________________

Transportation:

   School Bus Provided ___________     Walking Trip  _________     Other _____________

 

Other Needs:    __________________________________________________________

                        __________________________________________________________

Adopted:  March 7, 1985

Adopted Revision:  May 20, 1993

Adopted Revision:  August 25, 1994