I/we the undersigned parents and/or guardians of __________________________

                                                                                                         (student’s name)

a minor, do hereby refuse to grant permission to the responsible adult(s) supervising on school field trips, to any hospital, to any physician, or any other organization providing medical treatment to _______________________, during said field trip in the event that

             (student’s name)

I/we are not readily available to give my/our permission for such treatment. I/we base my/our decision to refuse medical authorization on my/our religious freedoms/beliefs. I/we agree to hold any adult who gives permission for medical treatment harmless and to release that individual from any liability in connection with me/us or them not granting such permission for treatment and, furthermore, I/we do hereby release, acquit, discharge, and covenant to hold harmless, the Pitt County North Carolina Board of Education, its agent and employees, from any and all actions, claims, demands, damages, costs, loss of services, expenses and compensation or other damages occurring or resulting on account of, or in any way growing out of me/us or them not granting permission for any emergency medical care or, medical treatment for my/our child, ____________________

                                                                                                                (student’s name)

during his/her participation in the above-described field trip. I/we understand that Pitt County Schools, its agents and employees, may not be incomplete control of a true emergency situation and cannot be held responsible for the actions of bystanders not participating in the above-described field trip and/or responding emergency medical personnel in a true emergency situation during his/her participation in the above-described field trip.

            I/we also specifically inform Pitt County Schools and the responsible adult(s) participating in the field trip that my/our child, ____________________________,

                                                                ( Student’s name)

has the following special medical needs, including allergies or other special medical needs: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

            In connection with these specific needs, I/we shall furnish to the responsible adult(s) supervising a field trip any necessary information, in writing, from my/our child’s personal physician regarding any special needs or conditions that my/our child may have together with instruction for appropriately dealing with such needs or conditions.

I/we acknowledge that I/we have carefully read the foregoing Medical Authorization Refusal Form and Release and know the contents apply to all field trips taken during the designated school year and that I/we sign this or the same as my/our own free act.

______________________________   ____________________________   ___________

             Parent/Guardian (please print)                                                Parent/Guardian (signature)                                       Date

______________________________   ____________________________   ___________

             Parent/Guardian (please print)                                                Parent/Guardian (signature)                                       Date

______________________________   ____________________________   ___________

             Student—if over 18 (please print)                                          Student—if over 18 (signature)                                  Date