Washington Dc Registration Forms 9.28.09

Gwinnett Goes to Washington (June 2 – 9, 2010) CONTRACT ASSUMPTION OF RISK AND RELEASE OF LIABILITY FIELD TRIP By signing this release I willingly accept all risks associated with this field trip or any activity incidental to the field trip. Some of the risk and dangers are listed below. I understand this list is not exhaustive: Travel to and from home and field trip location, overnight stay, food poisoning, theft, accident, falls, etc… I understand that these risks may at times result in personal or bodily injury, including death, and / or property damage. RELEASE OF LIABILITY In return for being allowed to participate in the field trip to Washington, D.C., I hereby release, hold harmless, and forever discharge, the adult chaperones on this trip from all liability arising from my child’s participation in this Field Trip. The adult chaperones for this trip are Bill Lewis, Dr. Donna Hinsey, Kelly Sloan, and Pat Visser. MEDICAL RELEASE If my child needs any medical treatment and my emergency contact cannot be reached, I agree to any treatment deemed advisable by any licensed emergency or medical personnel and to be financially responsible for any costs incurred as a result of such treatment. I am aware that the trip chaperones do not provide health insurance for my child, and that will provide a photo copy of the insurance card or allow a chaperone to carry my child’s health insurance card. STANDARDS OF CONDUCT My child will comply with all directions of the chaperones going on the trip. Below are some of the rules that are expected to be followed throughout the trip: 1. Remain with the group at all times. 2.

Remain in my hotel room when directed by a chaperone.

3.

Treat everyone that I come into contact with respect.

4.

Put electronic devices away when directed to do so.

5. I will not provide personal information (address, email, cell phone #) about myself to anyone outside the group while on this trip. 6.

A list of more specific rules will be given out to students prior to the departure for the trip.

I understand that any violation of the abovementioned rules or any behavior that threatens my safety or others will be grounds for removal from the trip. Any cost incurred to return a student home prior to the scheduled arrival time will be the responsibility of the parents. ACKNOWLEDGEMENT OF UNDERSTANDING BY SIGNING THIS RELEASE I ACKNOWLEDGE that I have read and understand this document and its legal significance. This release is freely and voluntarily given. _________________________ Parent Signature

_________________ Date

__________________________ Parent Signature

_________________________ Student Signature

_________________ Date

_________________________ Notary Public

_____________ Date ____________ Date

Home # _________________________ Cell (M) # ________________________ Cell (D)# __________________________ Work (M) # ______________________ Work (D) # _________________________ Cell Student ________________ Child’s insurance carrier ________________________________Policy # _____________________________

Insurance Contact Phone #__________________________________

In case of an emergency and I cannot be reached please contact ___________________ at #_____________________ o r #___________________________

WASHINGTON, D.C. FIELD TRIP (June 2-9, 2010) WHITE HOUSE CLEARANCE FORM

We are trying to obtain tickets for a tour of the White House. Because of strict security procedures, each person taking the tour must supply the following information in advance of the tour. For first name, please use your child’s birth name. Please complete and mail this from along with the other forms to : Bill Lewis, 4029 Green Gables Trace, Buford, GA, 30519.

Last Name (print) ____________________________ First Name (print) ___________________________ Middle Initial _______________ Date of Birth __________________________ U.S. Citizen (yes / no) _______________ Social Security Number (required for U.S. citizens) _________________ If not a U.S. citizen, Country of Origin __________________________