Makahiki Challenge Permission forms

Kamehameha Schools
Permission for Initiation of Medical Care and Release
Kaleiopapa Dorm
Activity: The Kamehameha School ________________________________________________________
(class/club/organization)
January 31, 2015
Inclusive dates are________________________________________________________
Itinerary includes_________________________________________________________
service project at Kualoa ranch Makahiki Challenge
Name of Student:
Student's Medical Doctor:_________________________________Phone_________________________
Student's Dentist:________________________________________Phone________________________
Name of Medical Insurance Subscriber ____________________________________________________
Our Medical Insurance Plan is ____________________________Number ________________________
As the parent(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 appropriate by the KS Medical or Health Services Department or Site Staff at my child’s
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 child’s 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 damages connected with or arising out 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 foods,
medicines, etc. Name medicine and dosage prescribed for asthma, allergies, etc.
Signed_____________________________________________________Date_____________________
(Father or Legal Guardian)
Signed_____________________________________________________Date_____________________
(Mother or Legal Guardian)
(rev. 01/05)
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 child has
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.
Insurance and Release: I /we represent that the student has insurance through my/our own insurance carrier
and that any claims for accidental injuries must be filed by me/us with my own insurance carrier before presenting a claim to
KS. Parents/legal guardians without medical insurance are encouraged to purchase 24 hour private student accident
insurance.
7.
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 and 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 child's participation in the trip/activity, my/our child's 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 the
Notice 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 including reasonable attorneys fees and costs, relating
to or arising out of the trip/activity, my/our child's transportation to or from the activity, or the rendering of required
medical procedures or treatment, if any, to my/our child.
10. Parental Consent
I/we have read the information about the Kamehameha Schools'
_______________________________________________________________________________________
(name of class, team or 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.
_______________________________________________________________
Father's/Guardian's Printed Name
_________________________________________________/_____________
Father's/Guardian's Signature
Date
_______________________________________________________________
Mother's/Guardian's Printed Name
_________________________________________________/_____________
Mother's/Guardian's Signature
Date
Address: _____________________________________________________
_____________________________________________________
Telephone:___________________________/_____________________________
home
work
(rev. 01/05)
SAMPLE
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
policies and 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 the trip:
3.
4.
•
Students will show consideration for others regarding personal property and privacy,
undue noise 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.
Chaperones play an important role in providing security, guidance and coordination for a
traveling group.
•
Students must realize that it is the duty of the chaperone to see that all school policies
and procedures are carried out, and cooperate with them in this regard.
•
Students are to be courteous to all chaperones. Disrespect or insubordination will not
be tolerated.
It is essential that students understand that rules regarding living arrangements while traveling
must be made so that the entire group may be accommodated.
•
Students will not leave hotel rooms in the evening without permission of the chaperone.
No student 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 drugs is
prohibited.
6.
Students are not permitted to smoke or gamble.
(rev. 01/05)
SAMPLE
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 cost for both him/her and the chaperone to meet
at the next point on the itinerary.
9.
Students may not borrow money from other students or chaperones. Travelers checks are
recommended.
10.
Friends or relatives may pick up students prior to their scheduled departure date and be
responsible for their return only if arrangements have been made prior to departure on the trip.
Requests must be 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 assigned
performances 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 student's/parents' expense. Serious
infractions may result in further disciplinary action up to and including release from KS.
Cut Here and Return Bottom Portion
______________________________________________________
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________________________
____________
Mother's/Legal Guardian Signature
Date
Date
Father's/Legal Guardian Signature
________________________ _____________
Student's Signature
Date
(rev. 01/05)
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