DIOCESE OF ORLANDO FIELD TRIP RELEASE FORM

EVENT: _____________________________________________________________________

DATE: ________ ORGANIZATION SPONSORING EVENT: ___________________________

ANTICIPATED DEPARTURE TIME: __________ ANTICIPATED RETURN TIME: __________

NAME OF STUDENT:_________________________________________________________

(Please print)

The undersigned, who is the parent/legal guardian of ___________________________

a minor(hereinafter referred to as “student”), on behalf of himself and Student, their personal

representative, assigns, heirs and next of kin, request Student be permitted to participate in the

aforementioned event,

1. Hereby releases, waives, discharges and convenants not to sue

______________________________________ (Sponsor), their officers, employees and agents,

all for purposes herein referred to as Releases, from all liability to the undersigned and Student,

their personal representatives, assigns heirs and next of kin, for all loss or damage, and /or

claims, demands, causes of actions or suits of any kind therefore, particularly on account of injury

to the person or property or resulting in the death of Student, whether caused by the negligence

of Releases or otherwise, while Student is a participant in the aforementioned event;

2. Hereby agrees to indemnify and save and hold harmless the Releases and each of

them from any loss, liability, damage, or cost they may incur while Student is a participant in the

aforementioned event, whether caused by the negligence of the Releases or otherwise;

3. Hereby assumes full responsibility for and risk of bodily injury, death or property

damage due to the negligence of Releases or otherwise while Student is a participant in the

aforementioned event;

4. Hereby agrees that if any portion of the Agreement is held invalid, that the balance

shall, notwithstanding, continue in full legal force and effect.

_______________________________________________ Date ____________________

(Signature of Parent/Legal Guardian)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

MEDICAL INFORMATION

In the event Student becomes ill, I authorize the directors or chaperones to obtain medical

attention at a physician’s office or hospital. Student is covered by the following medical

insurance:

Insurance Co. Name ____________________________________ Group #______________

Allergies: _____________________________ Chronic/Acute Illnesses: _________________

I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO REACH ME BEFORE MEDICAL

PERMISSION IS GIVEN TO TREAT MY CHILD.

Home Telephone ________________________

Mother’s Work # _________________________ ______________________________________________

Father’s Work # _________________________ (Signature of Parent/Legal Guardian)