Student Council Member (please print) :_________________________________________________________
ID #:
_____________________________ Birthday: _______________________ Year: Fr.
So.
Jr.
Sr.
_____ Check here if you prefer vegetarian meals.
Student Council Retreat
Please return this permission slip to E117 by 10:00 AM on Tuesday, April 22nd, 2014
There is a $30 fee to attend retreat. Please attach a check made out to DHS to your permission slip.
We want everybody on student council to attend retreat. If there is a concern about the fee, please
contact Ms. Kaplan, student council sponsor, at (224) 632-3226 or Mr. Verisario, student activities
director, at (224) 632-3020. Financial aid for retreat may be available.
TOWNSHIP HIGH SCHOOL DISTRICT NO. 113
DEERFIELD HIGH SCHOOL
LAKE COUNTY, ILLINOIS
PARENTAL PERMISSION TO PARTICIPATE
IN SCHOOL ACTIVITY AND WAIVER OF LIABILITY
Students have many opportunities to participate in various extracurricular activities at school as an outgrowth of
classroom interests or special interest clubs. On occasion it will be to their advantage to attend activities away
from school on an optional basis. However, the Board of Education of the School District cannot assume
responsibility for the safety and welfare of students while they are off campus beyond making reasonable
provision for their supervision by representatives of the School District designated to supervise the activity.
Your signature on page 2 constitutes and is evidence of (1) your consent to permit your child to participate in
the school activity; (2) your agreement to accept general liability for the participation of your child in the school
activity; and (3) your agreement to waive, release, indemnify and hold harmless the Board of Education of
School District No. 113, its members, agents and employees, from any and all claims and liability arising out of
your child’s participation in the school activity and transportation thereto and there from as described below.
_______________________________, has my permission to participate in the following school activity:
(Student name – please print legibly)
Student Council Retreat
Sunday, April 27th, 2014
at Holiday Home Camp
571 Outing St
Williams Bay, WI 53191
262.245.5161
http://www.owlsadventureed.com/about.php
I understand that my child will travel by school bus, leaving at approximately 8:30 A.M. on Sunday, April 27, 2014, and returning
at approximately 7:00 P.M. that evening.
THIS IS A SCHOOL SPONSORED EVENT AND ALL SCHOOL RULES WILL BE ENFORCED. IF THERE IS ANY
UNAUTHORIZED USAGE OF DRUGS, ANY USAGE OF ALCOHOLIC BEVERAGES, OR OTHER VIOLATIONS OF
SCHOOL RULES, PARENTS WILL BE NOTIFIED AND THE CONSEQUENCES WILL BE IMPLEMENTED BY THE
DEANS.
IN LOCO PARENTIS
On April 27, 2014 should my student require medical attention as a result of accident or serious illness, we do hereby grant and
bestow upon Deerfield High School Student Council Sponsors (Mr. Chamberlin, Ms. Klaas, Ms. Kaplan, Mrs. Gordon, Mr.
Verisario) permission and authority for and on our behalf to authorize any licensed medical practitioner to render medical aid and
treatment to the above-named person(s).
MEDICAL INFORMATION
List any medicines your student might take on the trip. Also list allergies your student has to drugs or medicines.
__________________________________________________________________________________________
__________________________________________________________________________________________
Any other relevant medical conditions:
__________________________________________________________________________________________
Consent:
_____________________________________________________________ Date: ______________________
(Parent or Guardian Signature)
_____________________________________________________________
(Parent or Guardian name - Please print.)
Phone #: Residence: __________________ Work:__________________ Cell: ___________________
Person to contact if parent/guardian cannot be reached:__________________________________
Phone #: ____________________________________________________
Student’s Cell Phone Number _____________________________________
Please return this permission slip along with a check for $30
payable to DHS by
10:00 A.M. Tuesday, April 22nd, 2014.
If you have any questions please contact Mollie Kaplan at (224)632-3226.