DELLTECH INSTITUTE OF COMPUTER EDUCATION

Ministry of Education Recognition

RCN 0043/10
P.O. Box 923,
Rakiraki

Phone: 6694568
E-mail Address:

M: 9269734

delltechrakiraki@gmail.com
Fiji Islands

FIELD TRIP
Parental/Guardian Consent Form and Liability Waiver
Participants Name:_____________________________________ Date Of
Birth________________
Parent/Guardians
Name:___________________________________________________________
Home
Address:___________________________________________________________________
Home Phone:_______________________

Work

Phone:________________________
E-Mail:___________________________
I, (Parent/Guardian)__________________________________________ ,
grant /do not grant permission for my child, (childs Name)
_____________________________________, to participate in this schoolsponsored event that requires transportation to a location away from
the school site.
This activity will take place under the guidance and direction of
school employees and/or volunteers from Delltech Institute of
Computer Education.
A brief description of the activity follows:
Type of
event:________________________________________________________________________________
Location of
event:_____________________________________________________________________________
Individual in
charge:____________________________________________________________________________

Date and time of departure:

return:________________________________________________________________
Mode of transportation to and from event:_________________________________________________________
As parent /or legal guardian, I remain legally responsible for any personal actions taken by the above named
participant. I agree on behalf of myself, my child named herein, to hold harmless, do not claim and defend
Delltech Institute of Computer Education, its officers, directors, or representatives associated with the event, from
any actions, claims, demands, damages, costs, expenses and consequential damage arising from or in
connection with my child attending the event or in connection with any illness or injury or cost of medical
treatment.
I hereby warrant that to the best of my knowledge, my child is in good health, and assume all responsibility for
the health of my child.
You should be aware of these special medical conditions of my child:____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______
Signature: ________________________________

Date:______________________________