SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

361/555-1234

Parental Authorization and Release Form

Must be completed, signed by parent/guardian, and returned to the Athletic Director/Coach.

Student: ______________________________________________________ Grade: _________________________________

I, ___________________________________, (parent or guardian’s name) of ______________________________________

____________________________________________(street address), City of ____________________________, County of

__________________________ State of am the (father/mother/guardian) of ______________________________ (student's name), a minor, who is enrolled in the XYZ Charter School, located at 719 Fourth Street, Anytown, Texas. I desire said child to go on any and all field trips and participate in any and all extracurricular activities with other children from the XYZ Charter School, during the school year____________. In consideration of said child being permitted to make such trips and take part in such activities and instruction, I hereby release the XYZ Charter School, its directors, teachers, employees, together with any volunteer carriers of such child without compensation, from any and all liability and responsibility in connection with such trips and activities, and hereby release all said parties from all liability by reason of any accident or injury suffered by said child while on said trips or engaged in such activities. I authorize the XYZ Charter School and its representatives to consent to medical treatment of my child in case of any illness or injury in connection with a school activity or school trip, such treatment to be administered by such physicians, other medical personnel, hospitals, and/or clinics as may be selected by the XYZ Charter School, or its representative. The XYZ Charter School is not financially responsible for emergency care or transportation.

Signature of Father/Guardian Signature of Mother/Guardian

Date: _________________________________________

SUBSCRIBED AND SWORN TO before me by said affiant on this day, to certify which witness my hand and seal of office this day of ___________________________ 20__.

My commission expires:

Notary Public in and for the county of Dallas, Texas.

NOTE TO PARENTS: Parental Authorization and Release forms are taken by teachers and coaches to all school activities off campus, including athletic and wilderness events. Past experience indicates that the following information is most helpful when responding to medical emergencies and seeking immediate treatment in emergency rooms.

Emergency phone numbers for parents: Home:____________________Work:__________________ Cell_______________

Emergency phone number of close friend or relative if parent cannot be reached:

Name: ________________________________________________________________

Home: ________________________ Work: _________________________ Cell: __________________________________

Preferred local physician: _________________________________________ Office phone: ______________________________

If it is necessary to transport your child to a local emergency room or trauma center, please list the hospital of choice.

Hospital: ____________________________________________________________________________________________

Family insurance or health plan: __________________________Group or policy number (if known): __________________

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