FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

As a parent or guardian of a student requesting to voluntarily participate in the AMC 8 Competition, I hereby

acknowledge that I have read, understood and agreed to the following:

I hereby give my permission for ___________________________________________, who attends Grade _____ at Meridian Park Elementary School, to participate in the AMC 8 on November 14, 2017.

Transportation for this activity will be provided by Parents make own transportation arrangements. District not providing transportation.

Student’s address: ______________________________________ City __________________________

Student’s home phone # _________________________Parents Work #___________________

Child’s Date of birth: __________________

Family Physician__________________________________ Phone #: ______________________

Medical conditions, medication information or allergies district should be made aware of:

_________________________________________________________________________

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

________________________________________ Phone #:_____________________________

________________________________________ Phone #:_____________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities.

______________________________________________________ ___________________________

(Signature of parent/guardian) (Date)

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Mar 15, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Washington State Math Championships (Blaine) field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on Mar 24, 2018 for the purpose of participating in the Washington State Math Championships (Blaine). Transportation for this activity must be arranged by each student's family. Please check one option:

□ Parent/guardian will drive student; early dismissal at 2pm on day of event.

□ Student will be driven by other Math Club parent.

Name____________________________________________ Phone #: -_________________________

Lunch :

□ I will provide lunch for my child. □ My child will bring money for Pizza.

Volunteers :

□ Chaperone 8:00 – 3:00 one per team □ Proctor 8:00 – 12:30

Student’s address: __________________________________________ City ____________________________ Student’s home phone # _______________Parents Work #_______________ Child’s Date of birth: _________ Family Physician___________________________________________ Phone #: _________________________ Medical conditions, medication information or allergies district should be made aware of: In the event of an emergency, I wish the following people to be notified in case I cannot be contacted: __________________________________________________ Phone #:________________________________ __________________________________________________ Phone #:________________________________ All information is considered confidential. It is extremely important you provide ALL medical information that

may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ _____________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities: - Participate in the Washington State Math Championships in Blaine

Registration (only the coach) 8:30 am.

Do the contest from 9:00 pm – 12:30 pm.

Picnic lunch at Peace Arch Park 12:45 to 1:45.

Awards from 2:15 to 3:00 pm. Meet your child at Meridian Park at 5:00 pm.

List potential dangers for the activity(s):

__________________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by April 11, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Grade 4 Math is Cool Championships field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on April 21, 2018 for the purpose of participating in the Math is Cool Championships . Transportation for this activity must be arranged by each student's family. Please check one option:

□ Parent/guardian will drive student; early dismissal at 2pm on day of event.

□ Student will be driven by other Math Club parent.

Name____________________________________________ Phone #: -_________________________

□ I give permission to my child’s driver to early dismiss my child at 1:30 pm on the day of the event.

Dinner: □ I will provide dinner for my child. □ My child will bring money for pizza.

Volunteers: □ Chaperone 3:00 – 8:00 one per team □ Proctor 3:00 – 8:00 □ Scorer 4:00 – 6:00

Student’s address: __________________________________________ City ____________________________

Student’s home phone # _______________Parents Work #_______________ Child’s Date of birth: _________

Parent name___________________________________________ Phone #: _________________________

Family Physician___________________________________________ Phone #: _________________________

Medical conditions, medication information or allergies district should be made aware of:

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

__________________________________________________ Phone #:________________________________

__________________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ _____________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities:- ● Participate in the Math is Cool Championships at Mount Rainer High School ● Arrive at the contest site by 3:15pm

● Registration (only the coach) 3:00 pm.

● Do the contest from 3:40 pm – 7:30 pm.

● Join your child for the College Bowl at 6:30 pm, or for the awards around 7:30 pm if you are volunteering

as a proctor.

List potential dangers for the activity(s):

_none__________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Feb 28, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Grade 5 Math is Cool Championships field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on Mar 10, 2018 for the purpose of participating in the Math is Cool Championships . Transportation for this activity must be arranged by each student's family. Please check one option:

□ Parent/guardian will drive student; early dismissal at 2pm on day of event.

□ Student will be driven by other Math Club parent.

Name____________________________________________ Phone #: -_________________________

□ I give permission to my child’s driver to early dismiss my child at 1:30 pm on the day of the event.

Dinner: □ I will provide dinner for my child. □ My child will bring money for pizza.

Volunteers: □ Chaperone 3:00 – 8:00 one per team □ Proctor 3:00 – 8:00 □ Scorer 4:00 – 6:00

Student’s address: __________________________________________ City ____________________________

Student’s home phone # _______________Parents Work #_______________ Child’s Date of birth: _________

Parent name___________________________________________ Phone #: _________________________

Family Physician___________________________________________ Phone #: _________________________

Medical conditions, medication information or allergies district should be made aware of:

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

__________________________________________________ Phone #:________________________________

__________________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ ______________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities:- ● Participate in the Math is Cool Championships at Mount Rainer High School ● Arrive at the contest site by 3:15pm

● Registration (only the coach) 3:00 pm.

● Do the contest from 3:40 pm – 7:30 pm.

● Join your child for the College Bowl at 6:30 pm, or for the awards around 7:30 pm if you are volunteering

as a proctor.

List potential dangers for the activity(s):

_none__________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Jan 24, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Grade 6 Math is Cool Championships field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on Feb 3, 2018 for the purpose of participating in the Math is Cool Championships . Transportation for this activity must be arranged by each student's family. Please check one option:

□ Parent/guardian will drive student; early dismissal at 1:30 pm on day of event.

□ Student will be driven by other Math Club parent.

Name____________________________________________ Phone #: -_________________________

□ I give permission to my child’s driver to early dismiss my child at 2:00 pm on the day of the event.

Dinner: □ I will provide dinner for my child. □ My child will bring money for pizza.

Volunteers: □ Chaperone 3:00 – 8:00 one per team □ Proctor 3:00 – 8:00 □ Scorer 4:00 – 6:00

Student’s address: __________________________________________ City ____________________________

Student’s home phone # _______________Parents Work #_______________ Child’s Date of birth: _________

Parent name___________________________________________ Phone #: _________________________

Family Physician___________________________________________ Phone #: _________________________

Medical conditions, medication information or allergies district should be made aware of:

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

__________________________________________________ Phone #:________________________________

__________________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ ______________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities:- ● Participate in the Math is Cool Championships at Mount Rainer High School ● Arrive at the contest site by 3:15pm

● Registration (only the coach) 3:00 pm.

● Do the contest from 3:40 pm – 7:30 pm.

● Join your child for the College Bowl at 6:30 pm, or for the awards around 7:30 pm if you are volunteering

as a proctor.

List potential dangers for the activity(s):

_none__________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Jan 25, 2018 As a parent or guardian of a student requesting to voluntarily participate in the MATHCOUNTS Chapter Competition field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on Feb 11, 2018 for the purpose of participating in the MATHCOUNTS Chapter Competition . Transportation for this activity will be provided by:

□ District not providing transportation. Parents make own transportation arrangements Lunch (if applicable):

□ I will provide lunch for my child. □ My child eat the pizza lunch provided by contest organizers.

Volunteers , please check any of the ways that you are willing to help: more information will be sent when I hear from the contest organizers.

◻ Set-up ◻ Registration ◻ Testing Monitor ◻ Clean-up ◻ Scorer ◻ Help as needed ◻ Proctor tests ◻ Concessions ◻ Chaperone a team of 4 students from my school

Student’s address: _____________________________________ City ____________________________ Student’s home phone # __________________________Child’s Date of birth: __________________ Parent name________________________________ Phone #: ______________________ Work #________ Family Physician_______________________________________ Phone #: _________________________ Medical conditions, medication information or allergies district should be made aware of: In the event of an emergency, I wish the following people to be notified in case I cannot be contacted: ___________________________________________ Phone #:________________________________ ___________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ ______________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities Participate in the MATHCOUNTS Chapter Competition

Registration (by the coach after the team has assembled) 8:30 – 8:50 am.

Do the contest from 9:00 am – 1:15pm

Awards from 1:15 to 3:00 pm. Meet your child at 1:00 pm.

List potential dangers for the activity(s):

_________________________________________________________________________________

TRIP INFORMATION I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Feb 3, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Shoreline Math Olympiad field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade ____ at Meridian Park Elementary School to participate in a field trip on Mar 10, 2018 for the purpose of participating in the Shoreline Math Olympiad . Transportation for this activity will be provided by:

□ District not providing transportation. Parents make own transportation arrangements Lunch (if applicable):

□ I will provide lunch for my child. □ My child will bring money for pizza.

Volunteers , please check any of the ways that you are willing to help: more information will be sent when I hear from the contest organizers.

◻ Set-up ◻ Registration ◻ Testing Monitor ◻ Clean-up ◻ Scorer ◻ Help as needed ◻ Proctor tests ◻ Concessions ◻ Chaperone a team of 4 students from my school (also check box on the back of this form)

Student’s address: _____________________________________ City ____________________________ Student’s home phone # __________________________Child’s Date of birth: __________________ Parent name________________________________ Phone #: ______________________ Work #________ Family Physician_______________________________________ Phone #: _________________________ Medical conditions, medication information or allergies district should be made aware of: In the event of an emergency, I wish the following people to be notified in case I cannot be contacted: ___________________________________________ Phone #:________________________________ ___________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

◻ I am available to be a Chaperone for a team of students from our school. I will arrive by 8:00 a.m. and will stay until the event is over (approximately 2:30 p.m.). I will meet my team in the cafeteria as they arrive and will stay with the team for the entire event. I will be responsible for my team’s punctuality, conduct, and respectful behavior throughout the day. I will stay until my entire team is picked up safely.

Student Code of Conduct Agreement – SMO 2018

I understand I have to behave respectfully and listen to my team’s chaperone while participating in the Shoreline Math Olympiad competition. I also understand that if my actions are disruptive or damaging in any way, that I will be asked to leave and will be disqualified from receiving any awards or prizes.

__________________________ ________________________________ ______________

Student Signature Parent/Guardian Signature Date

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ ______________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone) List of Field Trip Activities Participate in the Shoreline Math Olympiad at Shoreline Community College

Registration (by the chaperone after a team of four has assembled) 8:30 – 8:50 am.

Do the contest from 9:00 am – 12:00 noon.

Assume responsibility for your child between 11:40 and 1:30 unless you are volunteering at that time.

List potential dangers for the activity(s):

_________________________________________________________________________________

TRIP INFORMATION I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by Apr 18, 2018

As a parent or guardian of a student requesting to voluntarily participate in the Washington State Mathematics Council’s Middle School Mathematics Olympiad field trip, I hereby acknowledge that I have

read, understood and agreed to the following:

I hereby give my permission for _____________________________________, who attends Grade _____ at

Meridian Park Elementary School to participate in a field trip on Apr 28, 2018 for the purpose of participating

in the Middle School Mathematics Olympiad . Transportation for this activity will be provided by the following, check your choice:

□ Parents make own transportation arrangements.

Lunch

□ I will provide lunch for my child.

Volunteers:

□ Chaperone 8:00 – 3:00 one per team □ Proctor 8:10 – 12:55 □ Scorer 9:05 – 1:30

Student’s address: __________________________________________ City ____________________________

Student’s home phone # __________________________Child’s Date of birth: __________________________

Parent name________________________________ Phone #: ______________________ Work #___________

Family Physician___________________________________________ Phone #: _________________________

Medical conditions, medication information or allergies district should be made aware of:

_________________________________________________________________________________________

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

__________________________________________________ Phone #:________________________________

__________________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that

may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

I certify that my child has no physical conditions, which could interfere with his/her safety in this activity.

I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances.

___________________________ ___________ ______________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities Participate in the Washington State Mathematics Council’s Middle School Mathematics Olympiad

Registration (only the coach) 8:00 am. Meet your coach at 8:05 am.

Do the contest from 8:30 am – 12:50 pm.

Awards from 1:15 to 3:00pm. Meet your child at 1:00 pm.

List potential dangers for the activity(s):

__________________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the

school district will make every reasonable effort to provide a safe environment. I am fully aware of the special

dangers and risks inherent in participating in these activities, including physical injury, or other consequences

arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in

the activities.

___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2

FIELD TRIP ASSUMPTION OF RISK/PERMISSION TO PARTICIPATE

Please fill out these two pages (double sided if possible); return to your math group coach by March 1, 2018 As a parent or guardian of a student requesting to voluntarily participate in the Math is Cool Masters Competition field trip, I hereby acknowledge that I have read, understood and agreed to the following: I hereby give my permission for _____________________________________, who attends Grade _____ at Meridian Park Elementary School to participate in a field trip on March 19, 2018 for the purpose of participating in the Math is Cool Masters Competition . Transportation for this activity must be arranged by each student's family. Please check one option:

□ Parent/guardian will drive student.

□ Student will be driven by other Math Club parent.

Name____________________________________________ Phone #: -_________________________

Dinner: □ I will provide lunch for my child. □ My child will bring money for pizza.

Volunteers: □ Chaperone 9:00 – 3:00 one per team □ Scorer 9:00 – 3:00

Student’s address: __________________________________________ City ____________________________

Student’s home phone # _______________Parents Work #_______________ Child’s Date of birth: _________

Parent name___________________________________________ Phone #: _________________________

Family Physician___________________________________________ Phone #: _________________________

Medical conditions, medication information or allergies district should be made aware of:

In the event of an emergency, I wish the following people to be notified in case I cannot be contacted:

__________________________________________________ Phone #:________________________________

__________________________________________________ Phone #:________________________________

All information is considered confidential. It is extremely important you provide ALL medical information that may impact the care for your student in an emergency.

Page 1 of 2

I acknowledge that this activity entails known and unanticipated risks, which could result in physical or emotional injury, paralysis or death, as well as damage to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I certify that my child has no physical conditions, which could interfere with his/her safety in this activity. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the school district staff-in-charge to obtain emergency care for my student, neither s/he nor the district assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. ___________________________ ___________ _____________ _______________ (Signature of parent/guardian) (Date) (Work phone) (Home phone)

List of Field Trip Activities:- ● Participate in the Math is Cool Masters Competition at Moses Lake High School, Moses Lake WA. ● Arrive at the contest site by 9:00am

● Registration (only the coach) 9:15am.

● Do the contest from 9:45am – 3:00 pm.

● Join your child for the College Bowl at 12:55 pm (assuming you do not volunteer as a proctor)

List potential dangers for the activity(s):

_none__________________________________________________________________________________

TRIP INFORMATION

I have read the itinerary (detailing activities, events, date(s), places of lodging, etc.) and understand that the school district will make every reasonable effort to provide a safe environment. I am fully aware of the special dangers and risks inherent in participating in these activities, including physical injury, or other consequences arising from these activities. Being fully informed as to these risks, I hereby consent to my child participating in the activities. ___________________________________ ___________________________

(Signature of parent/guardian) (Date)

Page 2 of 2