Leland and Gray Performing Artists
“Journey East II: Sino-American
Performing Arts Exchange”
February 15, 2002
Dear Parent,
Your child will be
participating in the “Journey East” project in China during the current
semester. Please provide us with the information
requested below in case of an emergency.
List two persons to be contacted:
1. Name of Parent or Guardian: _______________________________
Address:
_______________________________________________
Phone number where person can be
reached: ______________ Home
______________
Work
2. Second person to be contacted: _____________________________
Address_________________________________________________
__________________________________________________
Phone number where person can be
reached: ______________Home
______________Work
3. Does your child have a medical condition or
history with which we must be familiar:
Yes________ No ________
If
yes, please describe the condition on the back of this form.
3. Does your child require medication? Yes ______ No ______
If yes, please
describe on the back of this form.
In the event that medical information is required, your
family doctor may have to be contacted.
Name: ______________________ Phone Number _________________
Address:
___________________________________________________
Your child will be participating in many activities while we are in China. This trip will require your child to be physically competent. A typical field trip while we are in China will include some fairly long bus rides, walking for a long distance and activities designed for your child to understand Chinese culture. At leisure times, your child might go out to streets where traffic may be busy. Although we will try to avoid your child going out into the street alone, we cannot exclude that possibility. This is a brief description of some of the activities your child might be involved in while we are in China.
If your child needs special accommodations, please let us know as soon as possible.
Please
read the information below and sign in the appropriate spaces.
I agree to assume all
risks of injury to my child or damage to his/her property and agree to hold
Leland and Gray and Windham Central Supervisory Union harmless for any and all
liability, claims or causes of action arising out of my child’s participation
in “Journey East.”
This hold harmless,
however, shall not apply to injuries or damage arising out of the sole
negligence of representatives of Leland and Gray and the Windham Central
Supervisory Union.
I warrant that my
child is in good health and has no medical condition that would prevent him/her
from participating in any such activities.
I permit the personnel of Leland and Gray and the Windham Central
Supervisory Union to obtain emergency treatment for my child if necessary.
I
give my permission for my child to participate in all program-related
activities.
PARENT
SIGNATURE: ______________________ DATE: ________________
STUDENT
SIGNATURE: _____________________ DATE: ________________
Please
return this form to Tom Connor at Leland and Gray by March 15, 2002.