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Liability and Consent Form

This document is a parent/guardian consent form and liability waiver for a field trip organized by MAS of Charlotte. It provides information about the child participating, including their name, birthdate, and emergency contact. The parent grants permission for their child to participate in the event and waives liability for MAS of Charlotte. Medical information about the child is also requested, including allergies, immunizations, and any physical or medical conditions. The parent signature at the bottom gives consent for emergency medical treatment if needed.

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220 views2 pages

Liability and Consent Form

This document is a parent/guardian consent form and liability waiver for a field trip organized by MAS of Charlotte. It provides information about the child participating, including their name, birthdate, and emergency contact. The parent grants permission for their child to participate in the event and waives liability for MAS of Charlotte. Medical information about the child is also requested, including allergies, immunizations, and any physical or medical conditions. The parent signature at the bottom gives consent for emergency medical treatment if needed.

Uploaded by

api-19917129
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Field Trip

Parent/Guardian Consent Form and Liability Waiver

Participants Name: _______________________________________________ Birth Date: ________________________


Parent/Guardians Name: ______________________________________________________________________________
Home Address: __________________________________________________________________________________________
Home Phone: ______________________________________ Work Phone: ______________________________________
E-Mail: ____________________________________________________________________________________________________

I, (Parent/Guardian) ____________________________________________________________, grant permission for my child,


(Child’s Name) ________________________________________________________________, to participate in this MAS organized event
that requires transportation to a location away from the MAS building. This activity will take place under the
guidance and direction of school employees and/or volunteers of MAS of Charlotte.

A brief description of the activity follows:


Type of Event: _____________________________________________________________________________________________________
Location of Event: _________________________________________________________________________________________________
Individual(s) in Charge: ___________________________________________________________________________________________
Date and time of departure: ________________________________________ Return: _____________________________________
Mode of Transportation to the Event: ____________________________________________________________________________

Volunteers to drive? ________ # attending: _____________


Driver’s Cellphone # _______________________ Cost (if any) ______________

As a parent/guardian, I remain legally responsible for any personal action taken by the above named participant.
I agree on behalf of myself, my child named herein, to hold harmless and defend MAS of Charlotte, it’s officers,
directors and agents, chaperons, or representatives associated with the event, from any and all actions, claims,
damages, costs, expenses, and all consequential damage arising from or in connections with my child attending the
event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree
to compensate MAS Charlotte, its officers, directors and agents, chaperones, or representatives associated with the
event or reasonable attorney’s fees and expenses arising therewith.

Signature: ____________________________________________________ Date: __________________________________________


Medical Matters:
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for
the health of my child.

Emergency Medical Treatment:


In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical
or surgical treatment. I wish to be advised prior to any further medical treatment by the hospital or doctor. In the
event of an emergency and you are unable to reach me at the above numbers contact:

Name: _________________________________________________________________________________________________________
Relationship: ________________________________________________ Phone: ________________________________________
Family Doctor: ______________________________________________ Phone: _________________________________________
Family Health Plan Carrier: _________________________________________ Policy #: ______________________________

Specific Medical Information: MAS Charlotte will take reasonable care that the following information
will be held in confidence:

Allergic Reactions (medications, foods, plants, insects, etc.): ___________________________________________________________


Immunization- Date of last tetanus/diphtheria immunization: _________________________________________________________
Does child have medically prescribed diet? _______________________________________________________________________________
Any physical limitations? ____________________________________________________________________________________________________
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
___________________________________________________________________________________________________________________________________
Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If
so date and disease or condition: _____________________________________________________________________________________________

You should be aware of these special medical conditions of my child:

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