Student Name: Deposit + packet due online or in school no later than October 5 RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT - PDF

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Student Name: HR: 8TH GRADE FIELD TRIP TO WASHINGTON DC TRIP SIGN UP PACKET Compete all 3 pages Turn in packet + deposit to Denise Casher in the Principal's office OR... Sign up and pay online at Penntours.com
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Student Name: HR: 8TH GRADE FIELD TRIP TO WASHINGTON DC TRIP SIGN UP PACKET Compete all 3 pages Turn in packet + deposit to Denise Casher in the Principal's office OR... Sign up and pay online at Penntours.com Deposit + packet due online or in school no later than October 5 RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT Please read the RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT on the reverse of this page carefully. Make sure you have a witness signature where indicated. Check this box IF YOU ARE WILLING TO PERMIT your student to participate in the upcoming overnight field trip to Washington D.C. on November 12-13, Student s Name (PRINTED) Signature of Parent/Natural Guardian Grade Date TURN OVER, AND COMPLETE THE REVERSE. BE SURE TO GET A WITNESS SIGNATURE. B U T L E R A R E A S C H O O L D I S T R I C T RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT TO: Butler Area School District, Its Board of School Directors, Superintendent, and Employees The Undersigned, the parents or natural guardians of the student, of (student s name) (student s address) hereby release and hold harmless the Butler Area School District, its Directors, Superintendent, and employees, with respect to any liability whatsoever concerning the undertaking of a trip to Washington D.C. on November 12-13, In executing this Release of Liability and Hold Harmless Agreement, the Undersigned acknowledge that they have been advised that neither the Butler Area School District nor the parties responsible for transporting and supervising the students in question can guarantee or assure the security of said students on the trip in question. The District does not provide uniformed or other security officers with respect to said trip nor does it assume such liability. The Undersigned will investigate and satisfy themselves with respect to the provision of security for the students on the trip in question and will hold harmless and release the District and its Directors, Superintendent, and employees, with respect to any liability arising out of the participation by said student on this trip. WITNESS the hands and seals of the Undersigned, intending to be legally bound hereby, and assuring to the parties that the Undersigned have legal authority to act on behalf of the student above named. In the event that a student has attained 18 years of age, both the student and his/her parents must execute the within Release. Witness Signature: Parent Signature: **Have someone over the age of 18 (other than then person signing on the right hand side) witness your signature. Parent/Natural Guardian Date: If this form is not filled in properly the entire packet and payment will be returned. Please get the witness signature required above! Student Name: History Teacher/Period: HR: Gender: male or female Please provide the following contact information: Parent/Guardian Name: Relation: Home Phone: Cell: Other: Parent/Guardian Name: Relation: Home Phone: Cell: Other: Other Emergency Contact: Relation: Home Phone: Cell: Other: Provide an address if you wish to receive any information about the trip (will not be given out or used for any purposes other than this field trip) PRINT CLEARLY: Student cell- OPTIONAL (for use on the trip only): Medical Insurance Information Insurance Company: Policy Number: Group Number: Family Physician: Phone: Administration of Over The Counter Medicine My child has permission to take the following if needed during the field trip. If he/she needs any of the following medications, he/she must ask a sponsoring teacher, and will be given the medication under a chaperone s supervision. You do not need to send any of these OTC medicines! (Please check any medications you allow your child to take if necessary.) Acetaminophen Antacid (tums) Imodium Ibuprofen Benadryl Dramamine I, the parent/guardian, do hereby release, discharge, and hold harmless Butler Area School District and Washington and PA Tours, their agents and employees, from any and all liabilities, and claim whatsoever for the administration of the above medication to my child/ward should there develop an allergic or other reaction from the medication. As the parent(s)/guardian(s) of the above-named student, I/we on behalf of myself/ourselves, my/our heirs, executors, administrators, and assigns, and on behalf of the above-named student do hereby release and discharge Washington and PA Tours, their employees, agents, and/or servants from any and all rights, claims, and/or actions which I/we and/or the above named student may hereafter have against PA Tours, their employees, agents and/or servants arising out of the aforementioned field trip. I understand that in the case of a medical emergency, every reasonable attempt will be made to contact the parent(s)/guardian(s) of the above-named student. If, however, I/we cannot be contacted and a medical emergency arises; I/we by affixing my/our signature(s) to this form give permission for my/our child to receive all necessary emergency medical care. I understand that if my child takes a daily medication at school or has emergency medication at school (bee sting or inhaler), the principal s designee (teacher or other staff person) will dispense this medication during the field trip. Parent/Guardian Signature: TURN OVER TO COMPLETE MEDICAL INFORMATION Has your child had any of the following (check all that apply): Seizure/convulsive disorder Mononucleosis/Hepatitis Asthma Diabetes Kidney Disease Absence of paired organ Concussion (if so how many times? ) Thyroid Disease Gastrointestinal Disease History of fainting due to exercise or other Been in the hospital except for tonsillectomy Undergone surgery Lower back pain Mental/Emotional problems requiring medical care Serious injury/illness Injury of a muscle, bone, joint, ligament or tendon *Note- If your child has ADD/ADHD or any mental health diagnosis requiring medication while he/she is in class, be aware that sustained focus and impulse control is needed at most of our stops just like it is in class. If you choose to send medication, make sure you follow the instructions below. It must be given to a school chaperone do not allow your child to keep these medications in their possession! If you checked yes to any of the above, please provide additional information: Date of most recent Tetanus immunization: Any known allergies? (food allergies, bee sting etc.) If yes, please list the allergy and any medication and/or steps of action: Is your child currently taking any medications? If yes, please list the medicine, reason for taking, and dosage: If you need to send any medication with your child, give it to the chaperone on their bus on the morning of the trip. Students should not keep any medication in their possession. Medicine must be in the original RX bottle with dosing information and any additional instructions. Remove any medicine that will not be needed while they are away -only send enough for the weekend! If there are any additional circumstances of which the tour coordinator or bus chaperons should be aware, medical or otherwise, please attach a page to this packet or contact Rebecca Green from PA Tours at All medical and other information is treated with strict confidentiality and only the chaperons who are with your child will be made aware of information needed to keep your child safe and healthy on the trip. I understand that the information provided will be treated with strict confidentiality and only shared with the chaperons responsible for my child on the field trip. Parent/Guardian Signature: Student Name: HR: Permission to Photograph I give Washington and PA Tours permission to photograph my son/daughter in a group setting and to use those pictures to promote the trip for future student tours. These pictures could be used in trip brochures, on the tour website, PowerPoint presentations for student and/or parent meetings etc. Discipline Policy As a parent, we know you want to be sure all the students have a fun, safe and educational time. In order for that to take place, the students must be respectful of themselves and of others at all times. One student cannot be allowed to ruin the experience for the remainder of the group. Butler Area School District students have represented themselves very well in the past. They are praised for their behavior time after time by personnel working at the different tour stops who deal with student groups on a daily basis. This is a compliment to the parents, chaperones and students involved. If behavior is an issue with any student, the chaperones will employ the following procedure: 1. Verbal warning 2. Assigned seat 3. Deny permission to remain with group at itinerary stops (will remain on bus with a chaperone) 4. Phone call to parent 5. Request to pick up child and remove from trip I understand the above discipline policy and agree to follow it. If my child s behavior is disruptive and the first four steps do not resolve the issue, I will make arrangements to pick them up wherever the group may be at that time. Please sign the statement below regarding the discipline policy. If you are not comfortable with the policy or cannot make arrangements to pick up your child in the event he/she is disruptive, then you should not send them on this field trip. If any of the above listed actions are needed, absolutely no refund will be granted. Tobacco, Controlled Substance and Firearm Policy I will not possess or use any tobacco products, alcohol, suspected controlled substance or weapons of any kind during the trip to Washington DC on November 12-13, I understand that if I violate this rule, I will immediately be excluded from participating in any further travel activity. The appropriate school officials (principal, superintendent) will be immediately notified and current Butler Area School District policies governing these offenses will be enforced. I will treat my fellow classmates, chaperones, medical staff, and teachers with respect. I understand the School District policies regarding profanity, disrespect, hazing, and harassment are applicable during all school related activities. I understand that if I violate any of the District policies I may be suspended from future overnight fieldtrips and appropriate disciplinary action in accordance with Butler Area School District policies will be taken. BY SIGNING BELOW, I HAVE READ AND AGREE TO ALL POLICIES ON THIS PAGE (Permission to Photograph, Discipline Policy and Tobacco, Controlled Substance and Firearm Policy) Parent Signature: Date: Student Signature: Date: TURN OVER TO READ + INITIAL TRIP PROTECTION POLICY The refund policy is as follows: the $50 deposit is not refundable after 10/5 and the $225 final payment is not refundable after 10/19. However, for families wanting added protection in case their child cannot attend the trip at the last minute due to illness, family emergency, or even if they are pulled for discipline reasons, PA Tours is offering affordable Trip Protection . While the $50 deposit is not covered, the policy does allow for a refund of the $225 balance up until the morning of the trip for any reason. Please read the Trip Protection policy below and decide if it is a good option for your family. Optional Trip Protection Policy (TP) Trip Protection (TP), is an optional insurance that can be paid any time between now and October 19th. If you choose to pay for this option now, your payment will be held for you until October 19th. If your child drops out of the trip before October 19th your $25 TP payment will be refunded. After October 19th, the TP payment will be applied as insurance for the $225 final payment and it is non-refundable. With TP, if your child drops out of the trip for ANY reason, (illness, change to sports schedule, pulled from trip for disciplinary reasons, etc.) you will receive a full refund of monies paid excluding fundraiser profit and the $50 non-refundable deposit. In order to receive a refund, you are obligated to contact Rebecca Green ( ) and/or Denise Casher ( ) before 6a on Saturday, November 12, 2016, should you need to cancel this trip. You may leave a message or text and you should receive a confirmation that we got the message. PLEASE INITIAL BESIDE ONE OPTION BELOW and send in the corresponding payment By selecting an option, you are either opting in to Trip Protection or opting out. If you purchase Trip Protection, you agree to the above policy. If you choose not to purchase Trip Protection, PA Tours Refund Policy at the top of this page prevails. I am sending in $50 (Deposit Only) I DO NOT want Trip Protection. I understand that I will not receive any refund for any reason if my child drops out of, or is removed from, this field trip after October 19 th. I DO want Trip Protection and will send in the $25 to school, or pay online, later (by 10/19). I am sending in $75 (Deposit + Trip Protection) I DO want trip Protection. My $25 will be held until 10/19 at which time it will be applied as Trip Protection. If my child drops before 10/19, my $25 payment will be refunded. I am sending in $275 (Payment for trip in full) I DO NOT want Trip Protection. I understand that I will not receive any refund for any reason if my child drops out of, or is removed from, this field trip after October 19 th. I DO want Trip Protection and will send in the $25 to school, or pay online, later (by 10/19). I am sending in $300 (Payment for trip in full + Trip Protection) I DO want trip Protection. My $25 will be held until 10/19 at which time it will be applied as Trip Protection. If my child drops before 10/19, my $25 payment will be refunded. Checks can be made to PA TOURS . Put your child's name in the memo line. A receipt for cash payment will be provided.
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