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CLARK HIGH SCHOOL PRIVATE CAR PERMIT and FIELD TRIP AUTHORIZATION I give permission for my son/daughter __________________________________________ (PLEASE PRINT STUDENT NAME) to travel to Key Club activities during the 2012 – 2013 school year. I agree to provide transportation, for my child, to and from Clark High School for these trips. Otherwise, I understand that he/she will be traveling in their own vehicle and will be supervised by a Clark County School District employee while at the activities. Further, I agree to remain with my child until the field trip begins and chaperones assume trip responsibility. I further agree to hold the Clark County School District, its employees and agents blameless of any injury or sickness directly caused by the negligence of persons other than employees or agents of the Clark County School District when such injury or sickness occurs during the activity. ------------------------------------------------------------------------------------------------------------------------------------------------------------I understand that during the school year my son/daughter may take part in field trips and educational excursions either in a bus, by private car, or on foot. I further understand that my child will be chaperoned by a responsible adult at all times while away from school and that the adult will take all necessary precautions to protect my child from harm and injury. In the event my child is injured or becomes ill while away from school on any of the aforementioned trips, I understand and authorize the chaperone to immediately seek medical attention for my child and contact me as soon as possible. I further hereby agree to hold the Clark County School District, its employees, and agents harmless of any injury or sickness directly caused by the negligence of persons other than employees or agents of the Clark County School District when such injury or sickness occurs during any of the aforementioned trips. I understand that I may revoke this permit at any time and either refuse to allow my child to take a field trip or to request that my child take certain trips which I feel would be to his/her advantage. If I desire to take either of these actions, I will notify the principal of the school in writing stating these requests. ============================================================================================= In case of an emergency, we need to contact you concerning your child. Please list your home phone, business phone, and/or another phone number where you may be contacted. Also, please provide the name and phone number of another responsible adult in the event we are unable to reach you at the numbers provided. These phone numbers are very important to us, in the event of any emergency. PARENT/GUARDIAN NAME: ______________________________________________________________________________ PARENT/GUARDIAN SIGNATURE: _________________________________________________________________________

PARENT/GUARDIAN HOME PHONE: _______________________________________________ PARENT/GUARDIAN BUSINESS PHONE: ____________________________________________ PARENT/GUARDIAN CELL PHONE: ________________________________________________

NAME OF EMERGENCY CONTACT (in the event parent/guardian cannot be reached): _______________________________ EMERGENCY PHONE NUMBER: ____________________________________________________

Membership Application page 3/7  

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