ARCHBISHOP COLEMAN F.

CARROLL HIGH SCHOOL

"sfiaring tlie yaiHl, 2Jui!£fing a yuture"

PARENT/GUARDIAN PERMISSION AND RELEASE FORM

For Athletic Participation, Off-Campus Activities & Fieldtrips

IJWe, the Parents and or Guardians request that Archbishop Coleman F. Carroll High School allow my/our child
_.,..,- ,.---,.,-- .,-- ---::-_-,-:-,,- to participate in the following activity, trip,
and/or event as indicated below and that IJwe hereby release and hold harmless from liability any volunteers and the
school employees involved, including administrators and supervisors.

Student---------F~i-~-t------~M~id~d-Ie-------------~L-~-t-------

Activity/Trip/Event __ :r:~"tGRo~e----.;...-_~----------------------
LocationlDestination .BtICI<.CU
, -r--
Ct2Z IrJ{lCKt:
'--
1\ Av-e)
~-------------------

Date \ 13 \ /10 Departure Time . '1~I 'J ,~ll Tl me Ct :4~ival Time 1'-: 0_0=--- _

Means of Transportation _B,--,-",u,-"s,,-' _

Supervision :::Jus-ho~ouse

Cost $__ 10=-- _ Each student should bring the following: _

Additional commentslinstructions:

UNLESS OTHERWISE STATED, STUDENTS ARE REQUIRED TO DRESS IN COMPLETE UNIFORM

CONTACT PERSON IN CASE PARENT CANNOT BE REACHED:

Name Telephone _

I. IIWe understand that adult supervision will be provided and that appropriate care will be taken for the health and safety of
all the students.
2. IJWe understand that VWe will be responsible and see that transportation is provided for my/our child should it become
necessary for the school authorities to send my/our child home because of disciplinary actions or for any other reason.
IJWe understand that the school authorities will contact us as necessary.
3. JJWe understand that school authorities will take action on my/our child per instructions on the school emergency card
should it become necessary to do so. Our health insurance company card information is as follows:

Health Insurance Company AgreementIPolicy Number

Date _ Parent/Guardian Signature _

Parent/Guardian Contact Telephone Number(s) _

STUDENTS WILL NOT BE PERMITTED TO PARTICIPATE UNLES

REVERSE SIDE OF TillS FORM IS COMPLETED BY EACH PERIOD TEACHER

10300 SW 167 AVE. a MIAMI FL 33196

(305)388-6700 ~ (305)388-4371 FAX