Parental/Guardian Consent Form

Section 1 - Contact Information

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Parent/Guardian's Name

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Section 2 - Off-site/Field Trip Consent Form and Liability Waiver

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I, (Parent or Guardian's name)

grant permission for my child/children to participate in school/parish events this year that may require transportation to a location away from the school/parish site.  The activities will take place under the guidance and direction of school/parish employees and/or volunteers of St. Thomas Aquinas/St. Mary school/parish.

As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor/minors ("Participant").  I agree on behalf of my self, my child/children named herein, or our heirs, successors, and assigns, to hold harmless and defend, its officers, directors of St. Thomas Aquinas/St. Mary school/parish and agens, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events, arising from or in connection with my child attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdioces of Dubuque, chaperons, or representatives associated with the events for reasonable attorney's fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Archdiocese of Dubuque.

Electronic Signature

Section 3 - Specific Medical Matters

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I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child/children.

Item A - Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment.  I wish to be advised prior to any further treatment by the hospital or doctor.  In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Other Medical Treatment:

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In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the activity that my child/children becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, 

On-site Nonprescription Medication Permission - I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child/children is already in attendance at the on-site program.

Administration of Medication - Archdiocesan Catholic School Board Policy 5141, items 9-10 (For Catholic School Programs Only).

9.  Dispensing of prescription medication

1. For Catholic school - Dispensing of prescription medication will be administered by a nurse or designated party with training and with the written consent of parent(s)/guardian(s).  Prescription medication must be provided to the school in the original labeled container containing the physician's name, name of the medication, and dosage/frequency to be given.  A record of each dose of medication administered will be documented in the pupil's health record.
2. Students Utilizing asthma or airway constricting prescription medication are allowed to administer their own dosage provided a completed consent form is on file in the school/program office.  Such forms must be filed annually.
3. Contraceptives will not be dispensed.  Iowa Code 280.16

10.  Dispensing of nonprescription medication may occur, provided the paren/guardian have signed and dated an authorization identifying medication, dosage, and time interval to be administered.  Nonprescription medications can be provided on off-site field trips if the parent/guardian signs a nonprescription medication authorization for each off-site field trip.