FORM C

PARENT/GUARDIAN CONSENT FORM

I hereby give my permission to ____________________________________________________________
To attend the off-campus activity detailed below: _____________________________________________
Name of off-campus activity: _____________________________________________________________
Purpose: _____________________________________________________________________________
Destination: _______________________________
Full Amount: ____________________________
Date: _____________________________________
Duration: _______________________________
Departure Time: _____________________________
Arrival Time: ____________________________
Boarding and Drop-off Area: ______________________________________________________________
Mode of Transportation: _________________________________________________________________
Proponent in-charge: _______________________
Cell phone no.:
Please check:
I received a detailed itinerary of the off-campus activity
I received a list of things the student should/should not bring

(
(

)
)

YES
YES

(
(

)
)

NO
NO

As parent/guardian of the above named student, I have fully read the off-campus activity itinerary
and I understand that there are risks and hazards associated with participation in these activities.
I hereby authorize qualified emergency medical professional to examine and in the event of
serious injury or illness, administer emergency care to the above named student. I understand every effort
will be made to contact me to explain the nature of the problem prior to any involved treatment.
In the event it becomes necessary for the proponent in charge to obtain emergency care for the
above named student, neither he/she nor the University assumes financial liability for the expenses
incurred because of the accident, injury illness and/or unforeseen circumstances.
The above stated Off-campus activity is an extension of the Universitys educational programs and
requires that the students manners and conduct be in accordance with the University rules and
regulations.

_________________________________________
PARENT/GUARDIAN (Signature over printed name)

___________________
Cell Phone no.

__________________
Home Phone no.

__________________________
Date Signed

________________________
Work Phone no.

I hereby declare that I am physically fit and voluntarily joining the above stated Off-campus
activity. I release _____________ from any liability arising from or may be attributed to my participation
in this event.
I pledge that my manners and conduct will, at all times, reflect credit upon my University, my
parents, and myself. I understand that the University rules and regulations apply for the entire duration
of our Off-campus activity.

______________________________________________
PARTICIPATING STUDENT (Signature over printed name)

__________________________
Date Signed

Noted by:

______________________________________________
PARENT/GUARDIAN (Signature over printed name)

__________________________
Date Signed