TRIP AND ACTIVITY CONSENT AND RELEASE FORM
ACTIVITY/TRIP NAME: DESCRIPTION/LOCATION/METHOD OF TRANSPORTATION: DATES: I, ________________________, am the parent or legal guardian of the minor child/children listed below. I give my permission for my child/children to participate in the activity or trip listed above. I understand that participation in KIPP includes physical education as well as classroom activities and off‐site trips. (For trips: I have read the information provided, if any, about the trip identified above.)
ACKNOWLEDGEMENT OF RISKS AND ASSUMPTION OF RISK AND RESPONSIBILITY (Whenever the word « child » is used in this form, the term refers to all of the children identified at the bottom. I understand that in signing this Trip and Activity Consent and Release Form I am consenting to the participation in trips and or activities for all of the children named above.) ACKNOWLEDGMENT OF RISKS: I recognize the fact that there are risks, foreseeable and unforeseeable, in the activities described above and in all trips and all travel related activities. I realize that my child could suffer death or injury or illness and require medical attention. I acknowledge these risks and confirm that my child’s participation in this activity or trip is voluntary. I consent to my child’s participation in this trip and all activities except for the following_________________________________________________. EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: My child’s participation in the above named activity or trip is voluntary and I assume all risks and full responsibility, on behalf of all parties including myself, my child, my child’s other guardians, and my child’s heirs and assigns, for (a) any and all losses incurred as a direct or indirect result of personal injury, accident, illness, or death, and (b) any and all damage to or loss of personal property arising out of, relating to, or in connection with any the above‐named activities or trips or any trip‐related activity. WAIVER AND RELEASE FROM LIABILITY: On behalf of my child, myself, my child’s other guardians and my child’s heirs and assigns, I hereby assume all risks and waive, release, and forever discharge KIPP and its trustees, employees, agents and its related entities from any and all liability, actions, and damages of whatever kind, including, without limitation, general, special, compensatory and punitive damages, for personal injury, property damage, negligence or wrongful death arising out of, relating to, or occasioned wholly or in part by the activity or trip or any trip‐related activities. MEDICAL AUTHORIZATION: I hereby authorize any medical treatment deemed necessary while my child is participating in any activities referred to above. In the event of illness or injury, I authorize KIPP and each of its employees, representatives and agents to take such measures as are available and appropriate in the judgment of the persons taking such measures, and I consent to emergency medical treatment and care which may be deemed necessary to be rendered. KIPP will make reasonable efforts to reach me in the event of an emergency requiring medical care. I HAVE READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I ASSUME THE AFOREMENTIONED RISKS, AND AGREE TO THE WAIVER OF LIABILITY AND TO HOLD KIPP HARMLESS
Child/Children (Print Name(s))_________________________________________________________________________ Signature of Parent/Guardian Date (Print Name) Emergency Telephone KIPP AMP Academy 1224 Park Place, 4th Floor, Brooklyn, NY 11213 Tel: 718-943-3710 Fax: 718-774-3673