KINGSWOOD OXFORD SCHOOL
PERMISSION SLIP/RELEASE FORM
As the parent/legal guardian of [___________________________], I give permission for my child
to participate in an Orientation Trip to Winona Camps in Bridgton, Maine. The activity will begin
at approximately 6:45am Wednesday August 29, 2012 and end at approximately 5pm Friday
August 31, 2012.
I understand and acknowledge that participation in the above activity may involve inherent risks of
injury to my child, including risks associated with transportation by motor vehicle. As a condition
of my child’s participation, I hereby release and discharge Kingswood Oxford School and its
faculty, agents, employees and volunteers from any and all liability stemming from my child’s
participation in the activity, including, without limitation, injury, death and property damage of
any description. I agree to indemnify Kingswood Oxford School for any costs or expenses arising
out of my child’s participation in the activity, including the cost of any medical care given my child
or any expenses or fees incurred as a result of any damage or injuries caused by my child in the
course of his or her participation in the activity.
I further consent that my child may be transported by any employee, agent, officer or volunteer of
Kingswood Oxford School to any hospital or medical facility in the event of a medical emergency. I
authorize medical treatment, including but not limited to emergency surgery or medical treatment,
and I assume all responsibility for medical bills that may result from such services.
Finally, should it become necessary for my child to return home early from the activity due to
medical reasons, disciplinary action or for any other reason, I will assume all transportation costs.
By signing below, I certify that I have read and agree to be bound by the above in its entirety.
Name of student (print):________________________ Date of birth: _____________________
Known allergies, including any allergies to medicine (continue on back of form if needed)
Any other medical problems that should be noted (continue on back of form if needed)
Name of parent/guardian (print):__________________________________________________
Signature of parent/guardian
Parent’s/Guardian’s phone: Home ___________Work ___________ Mobile___________
Contact person to notify if parent/guardian is unavailable (print name):____________________
Contact person’s phone: Home ___________ Work___________ Mobile___________
Family physician’s phone: ___________