PERMISSION SLIP

LIABILITY AND MEDICAL RELEASE FORM

I, the undersigned parent or legal guardian of _____________________________(student

name printed) do hereby grant permission for my student to attend the Key Club Convention from
March 26-28, 2010, in Boise, Idaho. I furthermore hereby release the _____________ School
District, its representative, agents and employees from liability for any injury to my child resulting
from any cause whatsoever while being transported to or from, or attending the named event,
excepting only such injury resulting from willful acts of representatives, agents, servants, and
employees.

1. I do voluntarily authorize _______________School District employees and/or others

chaperoning the event to administer routine first aid procedures and/or authorize emergency
medical treatment as may be deemed necessary by attending medical personnel.

2. I agree to indemnify and hold harmless the ___________________ School District and its
employees for any and all claims, demands, actions, rights of action, and or judgment by or on
behalf of the named person arising from or on account of said procedures and/or treatment
rendered in good faith and according to accepted medical standards.

3. I authorize my student to be excused from school March 26, 2010, to attend, and be
transported to the convention.

4. I understand that students are not allowed to have cars, or transport students to or from the
convention. Neither _________________ School District, or ______________ High School, will
be providing transportation to and from the convention. Transportation is provided by
commercial charter bus furnished by Le Bus. _________________School District, nor
_________________ High School, its employees or agents are not responsible in any way for any
accident or injury that might occur during the course of travel to and from any convention related
activity.

5. It is understood and agreed that convention attendees will use Le Bus to be transported to
some convention activities and meals that are held away from the main convention location.

The undersigned have read the trip guidelines as well as this form and understand them.
It is understood that if my student violates convention guidelines, he or she could be sent home at
the expense of the parent or legal guardian. It is expressly understood the affixing my signature
below constitutes agreement to all points of this document.

Date:________________________________________

______________________________
________________________________
Parent/Guardian Name Printed Parent Signature
Having read and understood completely the Key Club Convention trip guidelines, I do hereby
agree to follow the procedures and practices described. I fully understand that this is an activity
designed to educate Key Club members about the functions of the club. I will, to the best of my
ability, apply myself to accomplishing the purposes of the convention in order to more effectively
promote the activities of Key Club at _____________High School. I furthermore agree to
conduct myself at all times so as to uphold the finest qualities of a person representing
______________________ High School and the ______________________ School District.

___________________________________ _______________________________
Student Name Printed Student Signature