Permission Form – Floating Classroom Program



NAME (age 18 or over): __________________________________________________________


ADDRESS: __________________________________________PHONE (____)______________


CELL PHONE(____) ____________EMAIL ADDRESS_________________________________


Who should be contacted in case of EMERGENCY?

Name: ___________________________________ Phone:(include area code)_________________

Name: ___________________________________ Phone:(include area code)_________________

I will be participating in the Floating Classroom Program on _______________________(date). I understand that even though risks have been identified, prioritized and managed to the highest degree possible, unpredictable situations may be encountered on, in, or near the water which may pose a danger to participants.

The undersigned agrees to hold the field trip coordinators, the Texas A&M University’s Floating Classroom Program, and their representatives, harmless from any claim for injury to myself arising out of or in any way connected with the above named activity. It is also understood that possession and/or use of illegal drugs, alcohol, profane or abusive language, weapons, or vandalism may result in my removal from the program.

KNOWN ALLERGIES (medical or food):___________________________________________________

MEDICAL PROBLEMS , SPECIAL NEEDS OR MEDICATIONS :______________________________

_____________________________________________________________________________________



INSURANCE COMPANY________________________ POLICY #___________________


SIGNATURE:

____________________________________________________DATE______________