Claremont McKenna College - DOC

							                          PROGRAM PARTICIPATION PERMISSION AGREEMENT

                                                          JUNE 19-24, 2010

Your signature below will give permission for your son/daughter, _____________________________,
                                                                                                Student’s Name
to participate in Claremont McKenna College’s Step Up to Leadership Program. The program director is
Susan E. Murphy, Ph.D., who is a member of the faculty at Claremont McKenna College.

Your signature below acknowledges that you understand the following rules and restrictions for this
program.

1.       This one-week session will include activities on and off campus. Activities will include but are not
         limited to sports activities, swimming/water play, use of fitness room and athletic equipment, and
         other athletic facilities.
2.       Team-building activities may include but are not limited to moderate physical activity such as rope
         climbing and use of shovels or other tools.
3.       To ensure security, participants will be issued a key card for access to his/her dorm room and
         building entrance. Failure to return the key card at end of program will result in a charge to the
         participant of $125.
4.       To ensure security, participants will not be allowed to leave campus during the program or in the
         evenings without a camp chaperone. Anyone who is not a program participant is restricted from
         entering campus buildings and IS NOT ALLOWED IN DORMITORY ROOMS. THERE IS NO
         SMOKING ALLOWED IN ANY CAMPUS BUILDINGS.

Special instructions:
I will direct my son/daughter to comply with the instructions of school personnel in charge of this program. Should it be
necessary for my son/daughter to have medical treatment while participating in this field trip, I hereby give the school personnel
permission to use their judgment in obtaining the necessary medical service. I also give my permission to the physician elected
by the school or program personnel to render medical treatment deemed necessary and appropriate. Please make sure all health
information is complete and accurate on the Step Up to Leadership Health Form. Under the provisions of Education Code
35330, all persons participating in the program shall be deemed to have waived all claims against Claremont McKenna College
or the State of California for injury, accident, illness, or death occurring during or by reason of the program, excursions, or on-
campus activity.

                             I have read and understand this statement and agree to the instructions.


         My child CAN swim in water over his/her head.

         My child CANNOT swim in water over his/her head.

__________________________          ___________________________ ____________________                     __________________
   Name of Participant               Signature of Parent/Guardian Your relationship to child                 Date

________________________________________ _____________________________                        ________        ______________
   Street Address                          City                                                State           Zip

____________________________                  _____________________________
       Home Phone                                  Other Phone

If you have questions about any activities, please contact Jessica Briggs at the Kravis Leadership Institute
at Claremont McKenna College, phone (909) 607-4162.