Last Name        Grade         Student number   

Home phone    cell phone   

North Allegheny Lifetime Activities

Permission / Medical Form 2007-08

 

I give permission for  to participate in the Lifetime Activities program.

I understand the program activities include the following activities;

    Backpacking                Canoeing                    Climbing                                Kayaking

    Bicycling                       Caving                        Cross Country skiing           Hiking

    I understand there are inherent risks during participation in any of these activities, and physical injury may occur. I understand the school and its' leaders will do a reasonable and prudent job in minimizing any risks.

    I accept these risks and agree to release North Allegheny School District and the LTA advisors involved, as liable or responsible for any  injury due to unforeseeable risk. I also agree to be responsible, should any expenses arise due to injury incurred during participation in an LTA sponsored activity.

    I grant permission to the Advisors, to obtain proper health care for my child and act in their behalf, in the event I cannot be reached.

 

Name of Parent / Guardian 

 

Parent / Guardian signature                                                                                              

 

 Home phone            Work phone      cell phone

Emergency contact (if parents are unavailable)

 

Name          phone number   

Permission to administer Tylenol in case of headache or minor pain Yes    No

Name of Medical carrier    Group no.

Please list any medical concerns or medications;