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.