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The undersigned _______________________________, referred to as the parent(s) and lawful guardian(s) of _______________________________, a minor.
Parent(s) acknowledge(s) that said minor is authorized to take the following trip: _______________________________, and to engage in all activities incident thereto.
Parent(s) hereby appoint(s) _______________________________, as loco parentis, and authorize(s) the rendering of such emergency medical care as could be undertaken by the parent(s). The parent(s) hereby release(s) _______________________________ and its agents and employees from any and all acts taken in good faith during the trip.
Signed this _____ day of ______________________, 20____.
In the presence of:
Signature of Witness
Printed Name of Witness
Signature of Parent 1
Printed Name of Parent 1
Signature of Parent 2
Printed Name of Parent 2
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