Fillable FIELD TRIP AND/OR EVENT PERMISSION FORM (Columbia Gorge Community College)

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FIELD TRIP AND/OR EVENT PERMISSION FORM (Columbia Gorge Community College)

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PH: 503-792-3801
FAX: 503-792-3809
Gervais Elementary Gervais Middle School Gervais High School Samuel Brown Academy
EVENT: _______________________________________________________
DATE(S): _______________________________________________________
PLACE: _______________________________________________________
IMPORTANTINFORMATION&INSTRUCTIONSABOUTTHEEVENT:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Myson/daughterhaspermissiontoattend__________________________________________________event.
I,________________________________parent/guardiangrantpermissiontoanyadvisorfortheaboveevent
tomakepropermedicaljudgmentsformystudent________________________________(printstudentname),
incasemedical/dentaltreatmentisneededduetoaninjuryorillness.IunderstandthatIwillberesponsiblefor
allexpenses,doctorandhospitaland/orclinicthatmaybeincurredforallrelatedtreatmentstoinclude
prescriptionofmedication.Ialsounderstandthatanyadvisorortheschooltheyrepresentwhoisinvolvedin
makingmedicaldecisionswillnotbeheldliableinanyrespect.I,formyself,andonbehalfofmyheirs,
executors,administrators,successorsorthedelegates,herebyreleaseandforeverdischargetheGervaisSchool
Districtfromanyandalldemandsorclaims,knownorunknown,thatIhaveormayhaveagainsttheGervais
SchoolDistrictanditsstafforemployeesforanyandallharmordamagetomyson/daughtertotheirhealthor
propertyinanymannerresultingfromorarisingoutoftheirparticipationinandperformanceofactivities
relatedtothisevent.
Parent/GuardianSignature:__________________________________
______ Date:__________________
HomePhoneNumber:______________________________________ Cell:__________________________
MedicalInsuranceCarrier:____________________________________________________________________
MedicalInsuranceGroupNumber:____________________________ PolicyNumber:__________________
SchoolLunch
YesNoStudentMedicationsorHealthAlert:___________________________
FIELD TRIP AND/OR
EVENT PERMISSION
FORM
click to sign
signature
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PH: 503-792-3803
FAX: 503-792-3809
Gervais Elementary Gervais Middle School Gervais High School Samuel Brown Academy
EVENTO: _______________________________________________________
FECHA(S): _______________________________________________________
LUGAR: _______________________________________________________
INFORMACIONeINSTRUCCIONESIMPORTANTESOBREELEVENTO:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Mihijo(a)tieneel
permisoparaasistiraleventode_________________________________________.
Yo,comopadre/tutorde____________________________leconcedoelpermisoacualquierconsejeroparael
eventoanteriorhacerlosjuiciosmédicosapropiadosparamiestudiante________________________(nombre
delestudianteenmolde),encasoquesenecesitetratamientomedicoodentaldebidoaunalesióno
enfermedad.Yoentiendoqueyoseréresponsableportodoslosgastos,doctoryhospitaly/oclínicaquepueden
incurrirseparatodoslostratamientosrelacionadosincluyendolasrecetasdemedicamentos.Yotambién
entiendoquecualquierconsejeroolaescuelaqueellosrepresentanquiéninvolucrótomarlasdecisiones
médicasnoseranresponsablesencualquierrespeto.Yo,pormíparte,yennombredemisherederos,
ejecutivos,administradores,sucesoresolosdelegados,porlapresentelorelevoyparasiemprealDistrito
EscolardeGervaisdecualquieraytodareclamaciónodemandas,conocidasodesconocidasqueyotengao
puedatenercontraelDistritoEscolardeGervaisysupersonaloempleadosporcualquierotodoeldañoo
perjuicioamihijo/hijaasusaludopropiedaddecualquiermaneraresultandodeosurgirfueradesu
participaciónenylaactuacióndeactividadesrelacionadoaesteevento.
FirmadelPadre/Tutor:________________________________________ Fecha:__________________
NumerodeTeléfonodeCasa:______________________________________ Celular:__________________
ProveedordeAseguroMédico:_________________________________________________________________
AseguroMedicoNumerodeGrupo:_________________________NumerodePóliza:____________________
AlmuerzodelaescuelaSíNoMedicamentosoAlertadeSaluddelEstudiante:__________________________
FORMA de PERMISO de
PASEO y/o EVENTO
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FIELD TRIP ANDOR EVENT PERMISSION FORM (Columbia Gorge Community College)

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Completed 13 April 2022

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