USD 362 ACTIVITIES/FIELD TRIP EMERGENCY INFORMATION TO BE FILLED OUT AND SIGNED BY A PARENT/GUARDIAN AND STUDENT

Student Name (print): _________________________________________________________________

Grade:_________________

Parent/Guardian Name (print):___________________________________________________________________________________________________ Address:___________________________________________________ City__________________________________ Zip_____________________________ Home Phone:______________________________________ Mom Work:________________________________________________

Mom Cell:____________________________________________________

Dad Work:___________________________________________________

Dad Cell:______________________________________________________

EMERGENCY CONTACTS: TWO PERSONS WE CAN CONTACT IN THE EVENT NEITHER PARENT/GUARDIAN CAN BE REACHED:

1) Name (print):____________________________________________________________________ Phone:__________________________________________ 2) Name (print):____________________________________________________________________ Phone:______________________________________ BASIC MEDICAL INFORMATION: Check Yes or No and list date if Yes. Previous Head or Neck Injuries: Yes___ No___ Date___________Major Illnesses: Prior Heat Related Problems: Yes___ No___ Date___________

Medications: Allergies:

Current Insurance Carrier

___________________________________________ Policy Number:_____________________________________ RESPONSIBILITIES OF STUDENT AND PARENT

Participation in extra curricular activities or attendance on a field trip is both an honor and a responsibility. Students earn recognition for their achievements as representatives of their school and its ideals. Good physical conditioning and sound attitudes are integral to participation in Prairie View High School Activities Programs or attendance on a school sponsored field trip. It is a privilege to participate in extra curricular activities or participate in a field trip and this privilege is extended to all, provided that students are willing to assume certain responsibilities. A student participant must be a credit to oneself, the school and the community. PARTICIPATION: I give my permission for my child to participate in organized interscholastic activities including sports, clubs, or other extra curricular activities. I acknowledge that even with the best coaching, use of advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions these injuries can be so severe as to result in total disability, paralysis, quadriplegia, or death. I also acknowledge that participation in any athletics does not guarantee playing time at the varsity level. EQUIPMENT RETURN: I agree to be responsible for the safe return of all athletic and/or activity equipment issued to the above named student by the school. If the equipment can not be returned, I agree to make monetary restitution to the school for said equipment. The school acknowledges that wear and tear will occur on equipment and will not hold said student or parents monetarily responsible for normal wear. EMERGENCY MEDICAL SERVICE: If an emergency service involving medical action or treatment is required, I hereby consent for the above named student to be given medical care by the doctor or hospital selected by the school. Student Signature:________________________________________________________________________________________________________ Parent/Guardian Signature:________________________________________________________________________________________________ Notary Public:_____________________________________________________

Commission Expires:______________________________