2024/2025 School Year

Student Name*
First Last
Grade*
Field Trip*
Chaperone Availability*
Medical Information and Release
In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. On field trips that occur during the length of the school day, any prescription medication already provided to the school will be carried and administered by staff. If you are unable to reach a parent/guardian, contact:
Alternate Contact Name:*
First Last
Alternate Contact Phone*
Pertinent Medical Conditions (if applicable)
Please furnish medical information about your child/ward, which may be pertinent to his or her participation in the above-identified activity.
Digital Signature: Parent/Guardian Consent
In consideration for my child/ward's participation. I agree to reimburse and indemnify the parish/school for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found legally liable for injuries sustained by child/ward, this paragraph will not apply.

I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.
Parent Name*
First Last
By entering my full name, I attest that this constitutes my legal electronic signature on this form.
Address*
Street Address City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Date*
MM slash DD slash YYYY

Adult Liability and Medical Information Form

If you are an adult chaperone attending a field trip, you need to fill out the following form.

Adult Liability and Medical Information Form

ALL SAINTS CATHOLIC SCHOOL
Archdiocese of Milwaukee - Form 6153.1
Digital Signature: ADULT LIABILITY AND MEDICAL INFORMATION FORM
FIELD TRIP*
DATE OF FIELD TRIP*
MM slash DD slash YYYY
NAME*
First Last
Cell Phone*
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Consent to Participate and Indemnity Agreement:
I consent to participate in this activity. I agree to reimburse and indemnify the parish/school (understood to include the Archdiocese of Milwaukee) for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I may bring against the parish/school which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found legally liable for injuries sustained by me, this paragraph will not apply.
I understand that the parish/school does not provide any health, accident, or disability insurance for me, and I certify that I have adequate insurance or other monetary means available to me that will respond to any illness or injury that may occur during the activity.
I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that I will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.
Medical Information and Consent:
The following information will be used only in the event of an emergency in which you are unable to seek medical attention for yourself.
Physician's Name*
Physician's Phone Number*
Name of Medical Insurance*
Insurance Policy Number/member ID*
Dietary Needs/Allergies/Health
Special dietary needs, allergies, or mental/physical health issues we should know in the event of an emergency:
Medications:
- I am taking medication and will bring all such medications necessary, and medications will be well labeled.
Emergency Medical Treatment:
In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical treatment. I wish to have my spouse/parent advised prior to any further treatment by the hospital or doctor. In the event of emergency, please contact:
Emergency Contact Name*
Emergency contact day phone*
Emergency contact evening phone*
Emergency contact cell phone*
My health*
- I hereby warrant that to the best of my knowledge, I am in good health and I assume all responsibility for my health.
Participant Signature (Full Name)*
By entering my name, I attest that this constitutes my legal electronic signature on this form
Today's Date*
MM slash DD slash YYYY