Adopted:      07/21/2008                                                                                                                      

                                                                                         431.1Exhibit

Prairie Farm School District

WAIVER FORM RELEASING THE SCHOOL DISTRICT FROM LIABILITY CLAIMS

RE: Trips with Adult Approved by Parent or Guardian

Directions: This form is to be completed and returned to the principal or designee with a signed pre-absence form one day prior to the requested trip. If the form is not completed and approved absence will be determined as unexcused.

 ____________________hereby requests permission to travel with

            Student Name

_____________________       on a trip to       ____________________

Parent Approved Adult (21 or older)                            Location

on ________________.

            Date

The parent/guardian signature below constitutes approval for the above named student to travel with adult so named above. This form constitutes a release of the District from liability claims arising as a result of my student’s participation in this activity.

_________________________

 Parent/Guardian Signature

The adult signature below constitutes agreement to accept responsibility of said student and agreement to provide appropriate insurance coverage that will cover any injury or liability claims resulting from transportation incidents while on said trip.

_________________________

 Parent/Guardian Signature

Approved ________________________

Principal

Date ___________________

This form does not pertain to school-sponsored activities.

Cross Ref.:       431, School Attendance

                        431 Rule, Student Attendance Administrative Procedures

                        431.1 (2) Exhibit, Waiver Form - Trip to Postsecondary School