Participant's Name (Student) *
Participant's Name (Student)
Parent/Guardian's Name *
Parent/Guardian's Name
Home Address *
Home Address
Home Phone *
Home Phone
Birth Date *
Birth Date
to participate in this event that requires transportation to a location away from the school site. this activity will take place under the guidance and direction of school employees and/or volunteers from ATAM.
A brief description of the activity follows:
Type of Event: Field Trip
Atam provides each camper/student with transportation
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant.
I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend ATAM , its officers, directors and agents, chaperons, or representatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection with my child attending the event or in connection with any illness,injury or death or cost of medical treatment in connection therewith, and I agree to compensate the school, its officers, directors and agents, chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses arising there with.
Signature *
By Typing your name you are signing a digital signature
Date *
Medical Matters:
I hereby warrant that to the best of my knowledge, my child is in good health, and i assume all responsibility for the health of my child.
Emergency Medical Treatment:
in the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. i wish to be advised prior to any further treatment by the hospital or doctor. in the event of an emergency and you are unable to reach me at the above numbers, contact:
Name *
Phone *