Consent to Participate in Field Trip or Other Activity and Consent for Treatment

NOTE:  If the student named below is to participate in the field trip or activity, this form must be signed and returned to the school by the time the students are to depart for the field trip.  Permission by telephone is not acceptable.



            I,________________________________, the parent and legal guardian of _______________________________
give my consent for my child to participate in the field trip/other activity described here:
____________________________________________________________________________________________
on____________________________date.  I further give my legal consent and authorize any representative of West Bourbon Elementary School to authorize emergency medical treatment, including any necessary surgery or hospitalization, for my above-named child, for any injury or illness of an emergency nature he/she incurred while participating in the field trip or other activity noted above by any physician or dentist licensed in accordance with the provisions of the Kansas Healing
Arts Act K.S.A. 65-2801, and any hospital.

            I agree to pay and assume all responsibility for medical and hospital expenses and any emergency services incurred on behalf of my child.

            I acknowledge and agree that West Bourbon Elementary School is not responsible for any medical, hospital expenses and/or other charges that are incurred in the medical treatment or hospitalization of my child.  A photocopy of this document shall have the same force and effect as the original.  If my child requires emergency medical treatment, I understand that school personnel will make a reasonable attempt to contact me to seek my permission to authorize that treatment.  To facilitate contacting me, I agree to continue to provide current work and home phone numbers to the school.

___________________________________________________________________________________________

Parent or Legal Guardian                                                                                                    Date
 
 
 

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