Breakfree Outing
Student Permission Form

Your child will be participating in an outdoor recreation program sponsored by the Mid-Hudson Chapter of the Adirondack Mountain Club as follows;

Dates:

Outing Description:

Outing Location:

Schedule: (departure/Return times...)

Trip Leader contact: (Name and telephone)

Emergency contact: (Name and telephone)


Student Name ____________________________________ Student grade ______


Address __________________________________________ Phone ___________

I understand that every reasonable effort will be made to provide a safe environment for my child, but I am aware that all outdoor recreational and athletic events involve some degree of danger of risk and injury. I hereby agree for myself, all my family and heirs to release Mid-Hudson Chapter of the Adirondack Mountain Club, its trip leaders and organizers and the Adirondack Mountain Club, Inc. from all liability claims, including claims based on allegations of negligence. I agree not to assert any claim against Mid-Hudson Chapter of the Adirondack Mountain Club, its trip leaders and organizers and the Adirondack Mountain Club, Inc. for any injuries which may arise from my child's participation in this free program.

I ____________________________________, give my child permission to go on the outdoor trip outlined above.

Signature of Parent/Guardian ________________________________________

Date _____________

Home telephone number _______________ Work telephone number _______________.