ELKO COUNTY SCHOOL DISTRICT PARENT’S OR GUARDIAN’S ANNUAL CONSENT FOR FIELD/ACTIVITY TRIPS During the school year the teachers in your child’s school will schedule one or more field or activity trips which will take the students on educational experiences away from the school location. Parents will be notified by written notice of each of these trips as they are scheduled. This notification will be sent home with your child and will list the place, date, and time of the trip as well as any other information. Elko County School District personnel will take all normal precautions to ensure student safety on all field trips. We will appreciate you signing the bottom part of this sheet authorizing us to allow your child to participate in all trips for the school year. If you give your consent for the year, you may withdraw that consent at any time, for any reason, for one or more individual trips or for the remainder of the year.

School ___________________________________________________________________________ I hereby consent to you taking Student’s Name ___________________________________________________________________ on all trips during the school year, and I hereby expressly agree to relieve, indemnify, save and hold harmless the Elko County School District, the Board of Trustees of the District, and all its agents or employees from and against any and all liability or claims arising from injury or damage to person or property or both caused by or resulting from my child’s acts, omissions or conduct while on all trips. I also release and relieve the District and personnel from any and all liability or claims arising from injury or damage suffered or incurred by my child as a result of the acts, omissions, or conduct of any person other than the gross negligence of the District or its personnel. It is further understood that I shall have the responsibility for insuring that my child cooperates and conforms to the fullest extent with the directions and instructions of the school officials in charge. Parent’s or Guardian’s Signature______________________________________________________

Date_____________________________________________________________________________

MEDICAL INFORMATION: School_______________________________________________________________________________ Student Name_____________________________________DOB____________Age_______Grade_____ Address (Physical and Mailing)___________________________________________________________ Phone Number__________________________ Social Security Number___________________________ IMPORTANT—Please complete!! Physician____________________________________________ Phone Number____________________ Insurance Coverage ____Yes ____ No*

If yes, insurance carrier______________________________ Policy and/or Group Number_________________________

Is the student allergic to any medications? _____Yes _____No (If yes, please explain.) _____________________________________________________________________________________ _____________________________________________________________________________________ Is the student currently being treated for illness or injury? ____Yes ____No (If yes, please explain.) _____________________________________________________________________________________ _____________________________________________________________________________________ Does the student have any medical or physical restrictions? ____Yes ____ No (If yes, please explain.) _____________________________________________________________________________________ _____________________________________________________________________________________ Is the student required to wear or does he/she wear any type of medical identification? _______ Yes _______ No _______ Required _______ Not Required *Insurance is not required for attendance on field trips. Thus, I understand that since my child does not have insurance that as parent/guardian I will assume all financial responsibilities that may arise out of the need of my child to seek and receive medical treatment.

____________________________________________________ Signature of Parent or Guardian

___________________________ Date

In giving my consent to participate in school sponsored activities and go on school sponsored trips during this school year, I hereby expressly agree to relieve, indemnify, save and hold harmless the Elko County School District, Board of Trustees or the District, and all its agents or employees from and against any and all liability or claims arising from injury or damage to person or property or both caused by or resulting from my child’s acts, omissions or conduct while on all trips. I also release and relieve the District and personnel from any and all liability or claims arising from injury or damage suffered or incurred by my child as a result of the acts, omissions, or conduct of any person other than the gross negligence of the District or its personnel. It is further understood that I shall have the responsibility of advising my child of the risks, which are known or should be known for such participations and/or trips. I further agree to assume the responsibility for insuring that my child cooperates and conforms to the fullest extent with the directions and instructions of the school officials in charge.

___________________________________________________ Signature of Parent of Guardian

___________________________ Date

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