Providence Classical School Release Form

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Please complete one form for each student.

Student Name *

Date of Birth

YYYY

In the event of an emergency, we should try to contact: *

Parent Name and Phone Number

In the event of an emergency, we should try to contact (alternatives to parent):

Include Names, Phone Numbers and Relationship to child

Medical Permission

PCS may give my child (check all that apply):

Acetaminophen (Tylenol)

Ibuprofen (Advil, Motrin)

Antacid

Cough Drops

Diphenhydramine (Benadryl)

Hydrocortisone Cream

I understand all other medication my child needs to take during the day must be kept in the school office, and a parent must bring in the medication and sign a consent form.

Yes

Clear selection

PCS does not have a school nurse on staff. I give permission for PCS to provide medical care and make medical decisions with the understanding that they are not trained medical professionals and may make mistakes. I release PCS from all liability for negligence or error in such actions. In the event of an emergency, PCS may release my child to a medical professional. I understand all medication my child needs to take during the day must be kept in the school office.

PCS is not an allergen free school. It is the responsibility of the parent and child to be capable of avoiding allergens and treating reactions. Due to the number of students and allergies, PCS does not regulate student contact with possible allergens.

Physical education courses, school performances, recess, sports, other school sponsored activities contain risk of physical injury. I agree that my child may participate in these activities and I release and hold harmless PCS from any and all liability for loss, injury, damage, or claims arising out of my child's participation.

If your child has a serious medical condition or allergy, please provide details below.

Travel Release

I give permission for my student to participate in school sponsored events. These events include but are not limited to field trips, PE, walks, and outdoor classes. I will arrange transportation for my child to all field trips as they will be held when school is not in session and hold harmless PCS from any and all liability for any loss, injury, damage, or claim arising out of my child's participation in these events.

Photo/Media Release

PCS classrooms and events may be recorded or photographed for use on our website, catalog, socialmedia, instructional or promotional videos, etc. I give permission for PCS to use my child’sphotograph or photographic image in the ways listed above. I hereby waive any right that I may haveto inspect or approve the finished product in which a photographic or video image may be used,including the advertising copy or other matter that may be used in connection therewith.

General Release

I agree to hold harmless and release PCS from liability for any loss, injury, damage, or claim arising out my child's attendance at PCS. I have inspected the school and surroundings and understand that PCS operates as a small community in a shared space without extensive security and medical procedures.

This release form shall continue after my student's enrollment at PCS. Dropping off your student at PCS constitutes acceptance of this release form.

This form must be signed by each parent or guardian.

Parent Signature *

Date *

YYYY

Parent Signature *

Date *

YYYY

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