Cultural Connections Trip: NYC / Boston 25-26

First Name *

Middle Name *

Last Name *

Address *

Address 2

City *

State *

Zip *

Phone

Email *

Date of Birth *

Participation Permission *

I am the parent/legal guardian of the traveler, a minor. I hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child my permission to participate in the overnight, off-campus school trip.

Has this child had a recent surgery or illness? Please explain:

Does this child have allergies to food or medication?

If this child regularly takes medication, will it be with him for this trip?

Yes

No

Not Applicable

If you answered 'yes' to the above question, please list name of medication(s), dosage, time to be given, and any special instructions.

Prescribing physician's name

Medication Acknowledgment *

I hereby authorize the staff of Presbyterian Day School to administer the medication(s) listed above to my child while participating on the overnight, off-campus school trip. I understand that no medication will be administered except by PDS staff and that all medication must be in possession of a PDS staff member and not carried by student(s). I understand that all medications must be in the original container, labeled with the child’s name, medication name, and dosage instructions. Prescribed medication must also include the date and name of physician. By agreeing below I authorize and release the school and its staff from all liability.

I have detailed in the spaces above or on PowerSchool my minor child’s medical information and any physical conditions which may require attention, and I have listed all medications regularly used for said minor. I understand that failure to disclose medical information/conditions may result in cancellation of my child’s trip. In case of my child’s illness, PDS staff will attempt to notify whoever is designated as the emergency contact. In the event that the emergency contact cannot be notified, I authorize the staff of PDS to consent to any X‐ray examination, anesthetic, medical or surgical treatment, or hospital care required by my child. I hereby consent and give my permission to the staff of PDS or any attending physician to make medical decisions for my child if necessary under the circumstances.

Medical Consent and Overnight Waiver *

Yes

In consideration for being permitted to attend the overnight school trip and participate in the activities planned, I, on behalf of myself, my child, my legal representatives, heirs and assigns, do hereby release, waive, and forever discharge Presbyterian Day School and its officers, employees, volunteers, and agents, of and from any and all loss, damage, claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident that may occur as a result of my or my child’s participation in the related activities or any activities in connection with PDS, whether by negligence or not. I agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Tennessee, and that if any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

General Release and Waiver of Liability Consent *

Yes

Payment Information

The total cost of the trip covers flights, hotels, charter buses, tour guides, and chaperones (no chaperones for London trip). Food costs (except breakfasts) and souvenirs are excluded.

A $500 deposit is required to register. This amount will be added to your PDS account on June 1.

The balance of the trip cost will be added to your PDS account on October 1, 2024.

Please note that your tuition account must be paid and current before the trip.

Amount

$

Payment Method

Bill to Student Account

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

Verification code*

By Grade

Individual Registration

Medical Information

Medical Consent and Overnight Waiver

General Release and Waiver of Liability

Payment Information

Payment Information

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By Grade

Individual Registration

Medical Information

Medical Consent and Overnight Waiver

General Release and Waiver of Liability

Payment Information

Payment Information