Parental Consent Form | Alice Hoffman Young Writers Retreat

Acknowledgment of Risk and Consent for Treatment for Minor Participants in Event or Field Trip

Student's Name*
First Last
- Class/department: Education Studies
- Field trip leader: Professor Rob Linné, 516.877.4411
- Field trip destination: Adelphi University, Garden City Campus
- Field trip date(s): July 14-19, 2024 (Monday-Friday, 10:00 am - 3:00 pm)
- Equipment/supplies to be provided:
- By participant: Notebooks and pen
- Immunization required: N/A
- Physical activities to be undertaken include: N/A
- Risks inherent in this field trip include bodily injury due to: Students engaging in traditional classroom activities
Consent
I agree and give parental consent
I acknowledge that there are certain risks inherent in field trips, including, but not limited to, those indicated in Section 1, and that all risks cannot be prevented. I acknowledge that my minor child is physically able, with or without accommodation, to participate in this field trip and to use the equipment and/or supplies described above.

Should my minor child require emergency medical treatment as a result of accident or illness arising during the field trip, I consent to such treatment. I acknowledge that Adelphi University does not provide health and accident insurance for field trip participants and I agree to be financially responsible for any medical
treatment. I will notify the trip leader if my minor child has medical conditions about which emergency medical personnel should be informed. In case of an emergency, please contact me at the number listed below.
Phone*
(Include area code and extension, if applicable.)
Email*
Signature of Parent or Guardian*
First Last
Date*
MM slash DD slash YYYY
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Robert Linne

Professor

The School of Education, Ruth S. Ammon College of Education and Health Sciences

Contact

E-mail

linne@adelphi.edu

Phone Number

516.877.4411

Fax

516.877.4097

Location

Harvey Hall 227