Permission slips due

OCTOBER 22!
Turn it in before then and receive a
Halloween treat!

FIELD TRIP WAIVER OF LIABILITY

I TO BE COMPLETED BY MUSEUM STAFF

I understand the risks my child will be involved in, in connection with
YAC Halloween Party
Title of Activity

October 24, 2008 6:00-9:00pm

Date(s) of Activity Time of Activity

I understand that my child _____________________________________will be going to CMC

Full name of child
for an education/field trip experience with CMC staff at Cincinnati Museum Center

Transportation will be provided by N/A driven by N/A.

II TO BE COMPLETED BY PARENT(S)/ GUARDIAN(S)

*Please read carefully before signing*
I acknowledge that the experience/field trip may inherently include unforeseen dangers and hereby fully and expressly
assume all attendant risks and conditions (defective or otherwise) whether or not those risks or conditions are known to the
disclosed by Cincinnati Museum Center.

Furthermore, I release Cincinnati Museum Center from any and all claims, now existing or hereafter arising, for injury, loss,
or damage to person or property that may occur from the above-said risks which are hereby voluntarily assumed.

I am also aware that my child will be under constant adult supervision. However, I take full responsibility for my child’s
actions.

___________________________________ ________________________
Signature of Parent/Guardian Date

___________________________________ ________________________
Signature of Child Date

_________________________________________________ ________________________
Address City State Zip Code Home Phone No.

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Emergency Medical Authorization and Release of Information and Liability
This form enables parents and guardians to authorize or refuse the provision of emergency medical
treatment for children who become ill or injured while participating in Cincinnati Museum Center or
on the Cincinnati Museum Center property.

Should a child become ill or injured while participating in Cincinnati Museum Center programs
or while on Cincinnati Museum Center property, reasonable attempts will be made to contact the
parent, guardian, or other persons indicated on this page. If these persons cannot be reached and
medical treatment is needed, then this emergency medical authorization, or a copy of it, will be
presented to the hospital or practitioner providing treatment.

Applicable Information

Child’s Name Program Date

Address City State Zip

Name of First Parent or Guardian

Address City State Zip

Home Telephone ( ) Work Telephone ( )

Name of Second Parent or Guardian

Address City State Zip

Home Telephone ( ) Work Telephone ( )

Preferred Doctor Telephone ( )

Preferred Dentist Telephone ( )

Preferred Hospital Telephone ( )

Insurance Co. Policy Number

Facts or information which would be helpful to know about this child’s medical history, such physical
impairments, medications being taken, allergies, and special dietary needs etc. are:

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Authorization and Releases

As the parent or guardian authorized to sign this form, I hereby request that all reasonable attempts be
made to contact me should my child become ill or injured, but if I cannot be reached I hereby (please
indicate one):

Give

Do not give

my consent for transportation to and administration of any treatment deemed necessary by the
preferred physician, dentist and hospital indicated above, or if the appropriate preferred medical
provider is not available, then by other licensed physicians, dentists or hospitals which are reasonably
accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed
physicians concur that such surgery is necessary on an emergency basis before I can be contacted.

If indicated above that I am refusing to give this authorization, then I am hereby declaring that no

action should be taken, or that the following action should be taken if my child become ill or injured:

I hereby authorize the release of appropriate information to responsible persons in order to make the
necessary decision regarding my child’s medical treatment.

I assume the risk and financial responsibility for an illness or injury which may occur as a result of my
child’s participation in Cincinnati Museum Center programs, and I understand that nothing contained in
this form shall be construed to impose liability on Cincinnati Museum Center, or its staff, trustees and
agents who in good faith attempt to comply with my wishes as expressed in the form all present and
future claims which I may have related to my child’s participation in Cincinnati Museum Center
programs.

Signature: Date:
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