Quail Valley

ACKNOWLEDGEMENT OF RESPONSIBILIry
AND PERMISSION FOR STUDENT
PARTICIPATION IN SCHOOL.SPOTVSCiNED
TRIP

Student Name:

School-sponsored trip to:

Your chird has the opportunityto participate

in a schoor_sponsored trip. prease
comptete this form to provide-the ieachd;
with information relating to your child.
;";r;;;nlng
the students on the trip

Teacher:
Date:
List any physical limitations (temporary or permanent):

List any current medications (prescribed or

over the counter) taken:

List any allergies incruding reactions to medications,

environment: food, insects, and

Name of child,s physician:

Phone:
lnsurance company:
Phone:
Policy Number:

ACKNOWLEDGEMENT OF RESPONSIBTLIry

My signature below indicates that I giv.e.!y

child permission to participate in this
activity, to have any medications ao-ministered
tdt
schoor, and that t authorize any needed emergency w;;rd normaly be given at
medicar treatment. rarso
acknowledge that I have been informed that glnd Independent School
District has immunity
ro.t
from any tiability. Transportaiion wirr be provided by the
District or a commercial carrier.
Parent Signature:
Date:
Address:

Home Telephone: Work Telephone:

Emergency contact person:
Phone No:

Fort Bend Independent School District . 3500 euail Village Drive o Missouri City, Texas 77459
r (281) 634-5040. Fax {281) 634-5054