COULEE-HARTLINE SCHOOL DISTRICT #151

PARENTAL ASSUMPTION OF RESPONSIBILITY

For Students on School Trips Away From Home

To be completed by Parent and Student

I hereby grant Coulee-Hartline School District permission for my son/daughter

to travel to:

Date:

Departure time:

Return time: Please call the information hotline (681-0090) for the exact time.

Lunch/snack instructions:

Special instructions:

Allergies or other health problems (describe):

Medication:

Doctor and phone number:

My home phone:

Emergency number in the event I cannot be reached:

Type of insurance coverage/name of company:

Policy No.:

I have reviewed the itinerary and rules concerning this trip. I give permission for my son/daughter

to participate and I assume full responsibility for his/her conduct.

In the event of illness or accident, I authorize school-designated personnel responsible for this trip

to approve emergency medical care and give authority for the attending physician to exercise his or her

best judgment as to the requirements of such care.

Further, I agree to indemnify and hold harmless Coulee-Hartline School District #151.

Parent signature Date

I pledge that my conduct will at all times reflect credit upon parents, school and myself.

I understand school rules of conduct apply while on this trip.

Student signature Date