permission to participate form

8/9/2019 Permission to Participate Form

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INSTRUCTIONS TO STAFF/ADVISOR FOR USE OF

PERMISSION TO PARTICIPATE IN FIELD TRIP/ACTIVITY AND RELEASE FORM

(Staff Use Only)

1. The Permission to Participate in Field Trip/Activity and Release form is initiated when a KS staffmember/advisor is planning field trips/activities that occur outside of the normal school day hours

(e.g. weekend overnights, neighbor island or out-of-state travel).

2. KS staff/advisors must complete Section I and give to parents/legal guardians for their signature.a. Trip/Activity Planned: KS staff/advisor must describe in sufficient detail the place(s) to be

visited, dates, times and places of departure and return. Also, describe any known risks

associated with the planned activity in order to allow parents/legal guardians the opportunity

to make an informed decision. If staff/advisors are uncertain or would like assistance, staff

are urged to contact and consult with Legal.

b. Purpose of the Trip/Activity: KS staff/advisor should describe in sufficient detail thepurpose of the trip/activity.

c. Supervision of Students: KS staff/advisor should describe in sufficient detail the plan forsupervising students during the trip/activity, including the specific names of staff/volunteerswho will serve as chaperones and/or ration of staff/volunteers to students.

d. Transportation: KS staff/advisor should describe in sufficient detail the method oftransporting students, e.g. travel dates, name of air/bus carrier(s) and flight times.

e. Special Requirements: KS staff/advisor should describe in sufficient detail any specialrequirements that apply to this trip/activity (e.g. because of rough ocean conditions, the

student is expected to wear a life jacket at all times). If more space is needed, to describe

behavioral expectations, staff may attach additional sheets.

3. The parent/legal guardian must complete and sign Section II and return to KS staff/advisors prior tothe scheduled field trip/activity.

4. This completed and signed form will be effective for the scheduled trip/activity and must be renewedwhenever there is a new trip/activity.


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KAMEHAMEHA SCHOOLS

Permission to Participate

In Field Trip/Activity and Release

PART ONE: To be completed by teacher/advisor

Students Name:

1. Trip/Activity planned:

2. Purpose of trip/activity:

3. Supervision of students:

4. Special requirements:

5. Transportation and Board Information

Date Time Carrier Flight #

Air

Ground

Lodging

Comments:


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PART TWO: To be completed by parents/guardians:

6. Expectations and Instructions: I/we understand that my/our child is expected to, and my/our childhas been instructed by me/us to do exactly what he/she is instructed to do by the adult

staff/volunteer, and to comply with all special requirements, including those listed in #4 above.

7. Insurance and Release: I/we represent that the student has insurance through my/our own insurancecarrier and that any claims for accidental injuries must be filled out by me/us with my own insurance

carrier before presenting a claim to KS.

I/we request that the above-named student be allowed to participate in the trip/activity planned, and

I/we hereby specifically consent to his/her participation. If any emergency medical procedure or

treatment is required during the trip/activity, I/we consent to the trip/activity supervisor(s) taking,

arranging for or consenting to the procedure or treatment in his, her or their discretion.

In consideration for allowing my/our child to participate in the above-described field trip/activity and

on behalf of myself/ourselves, my/our personal representatives, my/our heirs, my/our assignees and

my/our child, I/we hereby waive and release any and all claims against KS and its Trustees, officers,

directors, agents, representatives, employees, in both their personal and professional capacities(collectively also KS), for injuries, liabilities, losses or damages connected with or arising out of

my/our childs participation in the trip/activity, my/our childs transportation to or from the

trip/activity, or the rendering of emergency medical procedures or treatment, if any.

8. Cancellation Policy: I/we understand that all trips/activities are subject to the terms described in theNotice Regarding KS Policy on Withdrawal of Travel Endorsement and Acknowledgement. I/we

am returning a signed acknowledgement of this policy if this trip involves off-island travel.

9. Indemnification Statement: In consideration for allowing my/our child to participate in the above-described trip/activity, I/we agree to indemnify, defend, and forever hold harmless KS from and

against any and all claims, proceedings, injuries, liabilities, losses, damages and expenses includingreasonable attorneys fees and costs, relating to or arising our of the trip/activity, my/our childs

transportation to or from the activity or the rendering of required medical procedures or treatment, if

any, to my/our child.

10.Parental ConsentI/we have read the information about the Kamehameha Schools

(name of class/team/club)

plans for a field trip/activity as described in detail in this form. I/we have signed this permission

form only after understanding and considering the information contained in this form.

___________________________________________________

Fathers/Guardians Printed Name

___________________________________________________

Fathers/Guardians Signature Date

___________________________________________________

Mothers/Guardians Printed Name

___________________________________________________

Mothers/Guardians Signature Date

Address: ___________________________________________

___________________________________________

Telephone : Home: __________________/Work: _____________________ Cell: ____________________


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Permission for Initiation of Medical Care and Release

Activity: The Kamehameha Schools

(class/club/organization)

Inclusive dates are:

Itinerary includes:

Name of Student :

Students Medical Doctor: Phone:

Students Dentist: Phone:

Name of Medical Insurance Subscriber:

Our Medical Insurance Plan is: Number:

As the parents(s) or legal guardian(s) of the above named student (my/our child), I/we understand that the

ultimate responsibility for the medical treatment of my/our child rests with me/us and my/our family and

agree to the following:

Limited Emergency and Non-Emergency Medical Service: I/we understand that Kamehameha Schools

(KS) offers limited student emergency and non-emergency medical services. I/we hereby authorize such

emergency and non-emergency medical services for my/our child as may be deemed necessary or appropriateby the KS Medical or Health Services Department or Site Staff at my childs school, and that KS will make

reasonable attempts to notify me/us as soon as possible of injury or illness to my/our child.

Referral and Consultation: I/we further authorize KS to refer my/our child to, or consult with, such

physicians or facilities as KS deems necessary or appropriate. My/Our preference (which is not mandatory) in

the event of such referral or consultation is stated in this Form. I/we understand that any charges for such

referral and consultation shall be our sole responsibility.

Release: In consideration of my/our childs enrollment in KS and on behalf of myself/ourselves, my/our

personal representatives, my/our heirs, my/our assignees and my/our child, I/we (a) waive and release any and

all claims against KS and its Trustees, officers, directors, agents, representatives and employees, in both their

personal and professional capacities (collectively also KS), for injuries, liabilities, losses or damagesconnected with or arising our of the rendering of medical treatment to my/our child; and (b) we agree to

indemnify, defend and forever hold harmless KS from and against any and all claims, proceedings, injuries,

liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to the

rendering of medical treatment of my/our child.

NOTE: Specify on a separate sheet any special medical needs or problems such as allergies to foolds,

medicines, etc. Name medicine and dosage prescribed for asthma, allergies, etc.

Signed: _________________________________________________ Date _______________

Father or Legal Guardian

Signed: _________________________________________________ Date _______________

Mother or Legal Guardian


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KAMEHAMEHA SCHOOLS

Notice and Acknowledgment of KS Procedures Governing Student Behavior

While Traveling with Kamehameha Student Groups

1. Students who participate in school-related field trips/activities are expected to observe the policiesand procedures contained in the applicable campus Student and Parent Handbook or program

guidelines.

2. The rules of common courtesy must be followed in order to have harmonious relationships during thetrip:

Students will show consideration for others regarding personal property and privacy, unduenoise during late hours, and the overall well-being of the group. They will exercise the

highest standard of conduct in order to reflect favorably upon themselves, their fellow

travelers and their school.

Students should not use improper language or be excessively boisterous and rowdy.

3. Chaperones play an important role in providing security, guidance and coordination for a travelinggroup.

Students must realize that it is the duty of the chaperone to see that all school policies andprocedures are carried out and cooperate with them in this regard.

Students are to be courteous to all chaperones. Disrespect or insubordination will not betolerated.

4. It is essential that students understand that rules regarding living arrangements while traveling mustbe made so that the entire groups may be accommodated.

Students will not leave hotel rooms in the evening without permission of the chaperone. Nostudent may travel away from the group alone at anytime.

Students are to remain in their assigned rooms after 10:00 p.m. Students will be assigned rooms and must not change rooms unless arrangements are made

with the chaperone.

5. The use, distribution or possession of alcohol, marijuana or other unprescribed drug is prohibited.

6. Students are not permitted to smoke or gamble.


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7. Students are not permitted to drive a car at anytime without the permission of the chaperone.

8. Promptness on a trip is very important. Students are to attend all scheduled activities on time. If a student is late and a chaperone must stay behind to wait for him/her, the student shall pay

any additional transportation costs for both him/her and the chaperone to meet at the nextpoint on the itinerary.

9. Students may not borrow money from other students or chaperones. Travelers checks arerecommended.

10.Friends or relatives may pick up students prior to their scheduled departure date and be responsiblefor their return only if arrangements have been made prior to departure on the trip. Requests must be

made in writing and signed by parents. It is recommended that parents/guardians complete the

Permission to Leave the Group form.

11.Students will attend all scheduled meals, practices, tours, scheduled programs and assignedperformances unless excused.

12. Illness is to be reported immediately to a chaperone.13.Disregard for the rules by a student may result in disciplinary action such as a call to the parents or

guardian and an immediate return home at the students/parents expense. Serious infractions may

result in further disciplinary action up to and including release from KS.

Cut Here and Return Bottom Portion

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KAMEHAMEHA SCHOOLS

Acknowledgment and Receipt of KS Procedures Governing Student Behavior

While Traveling with Kamehameha Student Groups

I/We acknowledge that I/we have received a copy of KS Procedures Governing Student Behavior While Traveling

with Kamehameha Student Groups and agree to abide by them.

__________________________ __________________ and __________________________ __________________

Mothers/Legal Guardian Signature Date Fathers/Legal Guardian Signature Date

_______________________________ ______________________

Students Signature Date


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Kamehameha Schools

Request for Medical Information and First Aid Kit

For KS Field Trip/Activities

The

(name of class, grade or organization)

has scheduled a field trip(s) on .

(day) (date)

Attached is a roster of those who will attend. Please advise me of any special medical conditions of the attendees. I

understand that this information is confidential to be used for medical emergency purposes only, that I must not

disclose this information unless there is a need to know, that I should store this list in a secure location and destroy

such information when no longer needed.

I understand that I need to bring a first aid kit with me during the field trip/activity and that staff from the Medical or

Health Services Department is available to instruct me about appropriate use of the contents.

I need a first aid kit for the trip/activity. I will make arrangements with the designated medical or

health services staff to pick one up the day before the field trip/activity.

I need a first aid kit for the school year for recurring field trips/activities of the class/club. I want to

make arrangements to use one for the school year.

I need training on how to use the contents of the first aid kit and will call the designated medical or

health services staff to set up an information session.

Name Extension


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KAMEHAMEHA SCHOOLS

Permission for Alternative Transportation

Name of Child _________________________________________________________________

School or Educational Site _______________________________________________________

Field Trip Name and Date ________________________________________________________

I/We understand that the standard transportation method for students at Kamehameha Schools is via a KS approved

school vehicle(s) from KS premises to the field trip site(s) and back to KS premises. I/We request permission to make

a change from this standard transportation method by the following method(s) [please check all that apply]:

_____I/We will transport my/our child and sign him/her in at the field trip/activity site.

_____ I/We have designated another adult to transport my/our child and sign him/her in at the field trip/activity site.

Name of responsible adult __________________________________________________

_____ I/We will transport my/our child and sign him/her out from the field trip/activity site.

_____ I/We have designated another adult to transport my/our child and sign him/her out from the field trip/activity

site.

Name of responsible adult __________________________________________________

In consideration for allowing me to deviate from KS scheduled method of transportation, and on behalf of

myself/ourselves, my/our personal representative, my/our heirs, my/our assignees and my/our child, I/We (a) waive

and release any and all claims against KS and its Trustees, officers, directors, agents, representatives and employees,

in both their personal and professional capacities (collectively also KS), for injuries, liabilities, losses or damages

connected with or arising our of my deviation from KS scheduled method of transportation for my/our child; and (b)

we agree to indemnify, defend and forever hold harmless, KS from and against any and all claims, proceedings,

injuries, liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to the

alternative transportation arrangements for my/our child.

___________________________________________________________ _____________________

Signature of Father/Legal Guardian Date

___________________________________________________________ _____________________

Signature of Mother/Legal Guardian Date


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KAMEHAMEHA SCHOOLS

Permission to Leave the Group

Name of Student _________________________________________________________ Grade ____________

Trip Name and Date _________________________________________________________________________

Date and Time of Separation

Date __________________________ Day of the Week _____________________

From _________________________am/pm to ___________________________am/pm.

Date and Times when child must remain with the group: ____________________________________________

Time and place for student to return with the group: ________________________________________________

Information about adult assuming responsibility for student (if not the parent(s)):

Name ___________________________________________ Phone: _______________________________

Address: __________________________________________________________________________________

Form of ID: ________________________________________________________________________________

Staff Member verifying identification: _____________________________ Date: ________________________

Adult acknowledging receipt of child: _____________________________ Date and time: _________________

I request permission for my child to leave the group with me/us/the above named adult (circle one) for the period

indicated above. I understand that reasonable care will be used to verify the identity of any adult taking temporary

physical custody of my child prior to the scheduled completion date/time of the field trip/activity. I understand that

my child may need to stay with the group during the period(s) indicated above, and I agree my child will be returned

to the group for said period(s). If for any reason my child is not returned to the group for said period(s), I assume

complete responsibility for all costs incurred in reuniting with the group later or missing the remainder of the trip, as

applicable.

In consideration for allowing my/our child to leave the group for the period indicated above, and on behalf of

myself/ourselves, my/our personal representative, my/our heirs, my/our assignees and my/our child, I/We (a) waive

and release any and all claims against KS and its Trustees, officers, directors, agents, representatives and employees,

in both their personal and professional capacities (collectively also KS), for injuries, liabilities, losses or damages

connected with or arising our of my deviation from KS scheduled method of transportation for my/our child; and (b)

we agree to indemnify, defend and forever hold harmless, KS from and against any and all claims, proceedings,

injuries, liabilities, losses, damages and expenses including reasonable attorneys fees and costs, relating to my/our

child leaving the group.

___________________________________________________________ _____________________

Signature of Father/Legal Guardian Date

___________________________________________________________ _____________________

Signature of Mother/Legal Guardian Date

permission to participate form

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