NSSD 112 Permission Slip

North Shore School District 112

Extracurricular

                      Parental Permission and Waiver of Liability

Program________________________Start Date_________________________

Program Description:

NSSD 112 affords every student with opportunities to explore personal interests and talents.  We believe that every student can find success and pleasure in one or several before or after school activities.  Participation in intramural sports, as well as any extracurricular activity or club, especially transportation to an away activity involves an inherent risk of injury.  However, the Board of Education of the School District cannot assume responsibility for the safety and welfare of students while they are on or off campus beyond making reasonable provision for their supervision by representatives of the School District designated to supervise the activity. 

Students requiring emergency medication, such as, but not limited to, Epi-pens, asthma inhalers or supplies for diabetes care, are encouraged to self-carry their medication. Please contact your school nurse for appropriate self-carry medication authorization forms and/or medication authorization forms. All medication authorization forms must be filled out and returned in order to participate in the activity. Accommodations for all children needing emergency medication must be arranged with the activity sponsor or coach. Please indicate on the bottom of this form if emergency medication is necessary.

I, _______________________ hereby authorize the staff of NSSD 112 to act for me according to their best judgment in any emergency requiring medical attention and I hereby authorize NSSD 112 and its employees and agents, in my behalf and stead, to administer or to attempt to administer medical aid when necessary for any injury or illness incurred while participating in a school sponsored activity and/or during the transportation to and from a school sponsored activity.  I authorize treatment of my child by a qualified physician or nurse in the event he/she should require medical attention.  I acknowledge that it may be necessary for the administration of first aid and/or emergency medications to my child to be performed by an individual other than the school nurse, and specifically consent to such practices.   As a guardian of a student in NSSD 112, I agree to hold harmless and indemnify the District, its employees and agents, either jointly or severally, except for willful and wanton conduct, from and against any and all claims, damages, causes of action, injuries, costs and expenses, including attorney’s fees,  incurred or resulting from the administration or attempt at administration of medical aid or the arrangement for emergency medical assistance and treatment.

I have read and fully understand that as the Parent/Guardian of this student, I accept general liability for the participation of my child in an extracurricular activity and waive and release all claims.  All emergency medication requirements necessary for my child are listed on this form. I understand that all medication authorization forms need to be on file with the school nurse.

___________________________                              ________________________

Parent/Guardian Signature                                          Date

___________________________

Student Name

Emergency Medication Required?  Yes or No  (Please circle and indicate what it is)