KEY CLUB MEMBER INFO

Name

Email Address
M or F
Gender

Street Address
City

Zip

Home Phone

Date of Birth
Cell Phone

School Sport/Team (if any)

Grade
S M L XL
T-Shirt Size (Circle)

School Activity (Drama, Band, Choiretc.)

Membership Requirements:
15 service hours per semester (30 hours total per year)
10 of 15 service hours must be with Key Club (5 of 10 hours must be at a
physical event)
$20 spring dues
Regular Meeting Attendance (Members cannot miss 2 meetings
without an excuse)
Failure to meet these requirements will result in probation for one semester. If probation falls in the Spring
semester, the student must make up any hours they were lacking from the previous semester. If the probation
falls after the Spring semester, the student will not be allowed to sign up for Key Club in the fall.

Student Signature

Parent Signature

Cypress Fairbanks ISD

101907

EFD
Exhibit

Cypress-Fairbanks Independent School District

Parent Permission Slip
(Date)
I hereby grant my son/daughter/ward ______________________________________________

(Student's Name)

my permission to attend and participate in any and all activities which are a part of

the _______________________________ instructional field trip. (School Name)

(School Name)
I understand that the class and instructional field trip activities will be supervised by adult
leaders. I hereby release the CYPRESS-FAIRBANKS INDEPENDENT SCHOOL
DISTRICT and all its supervisors, employees, and/or representatives from any and all
liability and/or claims and/or cause of actions, individually or collectively, for any damages
or injuries which might be received during class activity, on field trips or in traveling to and
from such field trip destinations, except for those for which the School District, its
supervisors, employees, and/or representatives do have effective insurance coverage-but only to the extent of such insurance coverage.
__________________________________________
(Parent's/Guardian's Signature)
(Address, City, State, Zip Code)

(Telephone number where you may be reached

during the field trip)
I understand that any misconduct (by school authority standards) on my part will result in
non-participation in future activities and that severe misconduct might result in my parent
being called to come and remove me from an instructional field trip activity.

ADOPTED

Page 1 of 3

Cypress-Fairbanks ISD
101907

EFD

Exhibit

Cypress-Fairban ks Independent School District

Medical Authorization F or m
I/We, being the parent(s) or legal guardian(s) of

a minor do

hereby appoint
of
Houston Texas to act
in my/our behalf in authorizing emergency medical, dental, or surgical care and
hospitalization for the above-named minor during a period of my/our absence on
(Date) This
document shall be presented to a physician, dentist, or appropriate hospital representative
at such time as emergency medical, dental, surgical care, or hospitalization
may be required
(Signature Parent/Guardian)

(Date)

(Street Address)
(City)

(Signature Parent/Guardian)

(Date)

(Street Address)

(State)

(Zip)

(City)

(Phone)
(Witness)

(State)

(Zip)

(Phone)
(Date)

(Witness)

(Date)

Hospitalization coverage for the above-named minor:

Name of Insurance Company or Government Carrier)
(Identification or Contract Number)

(Family Physician's Name)

(Family Physician's Phone Number)

Insurance Waiver Statement
Where no proof of insurance is established, parents of students must assume legal
responsibilities for expenses incurred for injuries to students that occur at school on cocurricular activities. I
have read and understand the insurance waiver statement.
(Signature Parent/Guardian)
(Student's Name)
ADOPTED

(Date)

(Signature Parent/Guardian)

(Date)

(Class Period)
Page 2 of 3

Cypress-Fairbanks ISD
101907

EFD

Exhibit

Cypress-Fairbanks Independent School District

Parent Information: Medication, Request

If your child will be requiring medication during the field trip, you must supply the nurse with

an empty prescription bottle with the proper dosage information on the label. The nurse will
put one dose of the medication in the bottle for the field trip. Please complete the following
Information.
I request that the following medication be administered to my child
______________________________ during the field trip.
Name of Medication: _____________________________________________________________
Dosage:
Time:_____________________________________________________________________________

______________________________________ _____________
(Signature of Parent/Guardian)
(Date)
If your child is on medication at school, but you do not want the medication administered
during the field trip, please notify the school nurse.

ADOPTED

Page 3 of 3

ADDENDUM TO
CYPRESS-FAIRBANKS INDEPENDENT SCHOOL DISTRICT
PARENTAL PERMISSION SLIP
For
CY-FAIR KEY CLUB
I,

the

parent/guardian

of

, who is a member of the Cy-Fair High

School Key Club, hereby declare my desires and grant my permission for my child with
regard to travel with the Cy-Fair Key Club to community service events.
I hereby grant my permission below by initialing each option with which I agree and
striking through those with which I do not agree: (PLEASE INITIAL ALL THAT
APPLY.)
I place no restrictions on how my child travels to Key Club events.
I give my child permission to drive to events within CFISD district boundaries.
I give my child permission to drive to events outside CFISD district boundaries.
I give my child permission to drive and to take other students to events as
passengers in his/her car.
My child does not have my permission to drive to events.
My child has my permission to be a passenger in a car driven by a fellow student.
My child may only be transported to an event in a car driven by a parent.
My child may only attend those events where transportation will be provided by
school bus.
I will be available to provide transportation to community service events
throughout the school year.

(Parent/Guardians Signature)

(Home Telephone Number)