Permission Form
– Floating Classroom Program
NAME of MINOR Child: __________________________________________________________
ADDRESS: _______________________________________PHONE
(____)______________
AGE ____________EMAIL ADDRESS____________________________________
PARENT/GUARDIAN NAME(S):_____________________________________________________________________
WILL A PARENT BE ATTENDING THE PROGRAM?_____________
If Not, what adult will be
responsible for the above child:______________________________________________________
EMERGENCY CONTACT NUMBERS: (include area
code)______________________________
The child named above has
my permission to attend and participate 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 the above named child arising out
of or in any way connected with the above named activity. If we the
undersigned parent/guardian cannot be contacted, we do hereby consent
to any x-rays, examinations, medical or surgical diagnosis or treatment
and hospital services that may be rendered to said minor under the
general or special instructions of an emergency room physician. It
is understood that this consent is given in advance of any specific diagnosis
or treatment, and that I/we the undersigned are responsible for all
charges for the above mentioned diagnosis, treatment, or hospital care.
It is also understood that possession and/or use of illegal drugs,
alcohol, profane or abusive language, weapons, or vandalism may result
in this child being removed from the program and sent home at my expense.
KNOWN ALLERGIES (medical or
food):___________________________________________________
MEDICAL PROBLEMS
, SPECIAL NEEDS OR MEDICATIONS :______________________________
_____________________________________________________________________________________
INSURANCE COMPANY________________________ POLICY #___________________
PARENT/GUARDIAN SIGNATURE:
____________________________________________________DATE______________