CLEAR CREEK HIGH SCHOOL
CLEAR CREEK SCHOOL DISTRICT RE-1
185 BEAVER BROOK CANYON ROAD – EVERGREEN, CO 80439
303-679-4600
CONSENT FOR ATTENDANCE - PROM
I hereby give my consent and permission for
(student) to
participate in and attend: 2015 Prom at Heritage Square 18301 West Colfax Ave . Golden, CO.
Saturday, May 2nd, 2015, 7p.m.-11:00p.m. Tickets are $40.00 (single); $70.00 (couple) .
As parent and/or legal guardian of the student, I understand and agree that I am responsible for the
student and in the event the student should violate the rules established that:
1)
I will be responsible for and hold the Clear Creek School District, its agents, servants, and
employees harmless from any and all damage to persons or property caused by acts of the
student.
2)
In the event of a serious violation of the rules established for students, I understand I will be
notified immediately and my student will be sent home.
3)
I further understand that the student will travel by private vehicle, and I consent and agree to
hold Clear Creek School District, its agents, servants and employees harmless from any
claim.
4)
I understand and agree that the Clear Creek School District and its servants, agents and
employees do not assume any liability for loss or damage to any personal property owned
by student and/or parent/guardian.
5)
I hereby agree to save and hold the Clear Creek School District, its agents, servants and
employees harmless from any claim, demand or cause of action of whatsoever nature or
kind excluding acts of willful misconduct or gross negligence arising out of, or incurred as a
result of the student’s attendance and participation, or as a result of any injuries, loss or
damage suffered or incurred by myself or the student during the event.
THE CONDITIONS AND STATEMENTS ON THE REVERSE SIDE ARE AN INTEGRAL PART OF
THIS AGREEMENT
STUDENT NAME (PRINT)
SIGNATURE OF STUDENT
PARENT NAME (PRINT)
DATE
STUDENT ADDRESS
PARENT HOME PHONE
SIGNATURE OF PARENT/GUARDIAN
PARENT ADDRESS
WORK PHONE
Over - must be completed
DATE
(If different)
EMERGENCY PHONE
I hereby represent to Clear Creek School District that the student is in good physical health.
I hereby grant permission and give my consent for the above named student to 1) be treated by any
qualified nurse, physician or surgeon as may be deemed necessary by Clear Creek School District
personnel, its agents, servants or employees during the event; 2) be administered medication
and/or emergency first aid care as may be necessary or appropriate; 3) receive treatment in
hospitals, medical clinics or elsewhere in the event of accident or illness.
To assist in the medical care or treatment the medical information supplied below on the Health
Information Form is true and accurate. I will hold the Clear Creek School District and its agents,
servants and employees harmless and indemnify them from any claim, cause of action or demand
arising out of any form of (or the lack of) medical or emergency treatment rendered to the student.
The student, by his/her signature hereto, fully agrees and consents to the foregoing.
THE CONDITIONS AND STATEMENTS ON THE REVERSE SIDE ARE AN INTEGRAL PART OF
THIS AGREEMENT.
HEALTH INFORMATION FORM
Must be completed
Student Name
Parent Name
Address
Home Phone#
Parent Work Phone#
Parent Cell Phone#_______________________
Person(s) who we may contact in an emergency if parents cannot be located:
Name
Phone#
Name
Phone#
Physician
Phone #
Health Insurance
Policy #
Please list any significant health problems this student has of which sponsors should be aware:
Does this student have allergies to any drugs? (Please list)
Please list all medications that this student is taking now:
TICKETS ARE $40.00 (single); $70.00 (couple). THIS FORM MUST BE COMPLETED AND
RETURNED AT THE TIME OF TICKET PURCHASE.
TICKETS WILL NOT BE SOLD AFTER April 30th. NO EXCEPTIONS!