Day Trip Parental Consent

Field Trip Parental Consent Form & Indemnity Agreement — For Day Trips

Please fill in your information, read the consent statements, and sign at the bottom. On submission you’ll generate a completed PDF that’s emailed to the organizer (and copied to the parent/guardian email below as a receipt). Required fields are marked with *.

Participant Information

First name *

Middle initial (optional)

Last name *

Date of birth *

Gender

Student T-Shirt size

Parent/Guardian Contact

Parent/Guardian's name *

Home address *

Home phone *

Business phone (optional)

Parent/Guardian email *

Activity / Event Details

Type of event *

Date of event *

Destination of event *

Student cost

Individual in charge *

Estimated time of departure

Estimated time of return

Mode of transportation

Emergency Contact

Name & relationship *

Phone *

Adult Attending

Is a parent or other adult attending this event with the student? If Yes, the Archdiocese Adult Liability Waiver will also be generated and signed.

No Yes — an adult is attending

Medical Information

Medications (names, dosage, frequency — or leave blank if none)

Allergic reactions (medications, foods, plants, insects, etc.)

Special medical conditions to be aware of

Family doctor

Phone

Family Health Plan Carrier

Policy #

Consent & Release Statements

I, the parent/guardian, grant permission for my child to participate in this parish/school event that requires transportation to a location away from the parish/school site. This event will take place under the guidance and direction of parish/school employees and/or volunteers from Cub Scout Pack 9207, St. Joseph Church and School Rosemount.

I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("student/participant"). Further, 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.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the organization, its officers, directors, employees and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter "Releasees"), from any claim, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Releasees and is not related to communicable disease.

Communicable Disease Release, Hold Harmless & Indemnification Agreement: I agree to hold Releasees harmless, release, defend, and indemnify Releasees for any communicable disease claim arising out of the above Event that is brought against Releasees by myself, participant, my family members, heirs, assigns, executors, and personal representatives. I understand and agree this communicable disease release, hold harmless, and indemnification agreement includes claims based on the actions, omissions, or negligence of participant, myself, and others, including, but not limited to the Releasees.

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.

As Parent or Guardian, I agree to all of the above stated considerations and conditions. I understand my signature below will be applied to every required signature block on the form.

Signature

Parent/Guardian signature *

Date *