Lgkgland Christian Apademy - Lakeland Christian Academy

Lgkgland Christian Apademy
Field Trip Policies for Adult Volunteers
I uxderstancl my primary responsibilify is to irelp fhe LCA
f*a*:*ring
the studeuts in n way fFlat ryr,:q{is tlr exce*d:i L,C.il
stnlf to cai"e fsr
stanrlards of cane.
Person?l Beloneings
I understand I may not have itt *y possession a firearm of any kind. If using
my personal vehicle to transport LCA students to or from an off campus
event, I understand I may not have a firearm of any kind in my vehicle.
Medical Attention
I understand I may not give anv medication to a student at any time. For
students, I agree to seek immediate medical attention from an LCA staff
member.
Interaction with Students
agree to observe the Three-Person Rule. I understand that I may not be
alone with any child. In the presence of children there will always be at
I
least three individuals.
No Corporal Punishment
I understand LCA does not allow corporal punishment, including any form
of spanking. For any child who exhibits a discipline problem, I agree to
retum the child to his/her LCA teacher. I understand, while octing as an
Adult Volunteerfor LCA,I muy not spank my own child at any time.
No siblines
I understand special events planned by LCA are strictly for specific LCA
ciasses. Siblings of'Adult Volunteers and LCA students from other classes
are not allowed.
Nq_cellphong
I understand LCA students will receive the undivided attention fiom all
Adult Volunteers. Cell phone, pagers, etc. are to be turned off during the
entire event. No exceptions.
Signature
Date
Lakeland Christian Academv
Authorization for Criminal Records Check
I hereby authorize Lakeland Christian Academy to obtain any information which pertains
to any records of convictions contained in its files or in any criminal {ile maintained on
me whether local, state, or national. I hereby release Lakeland Christian Academy from
any and all liability resulting from such a disclosure.
I understand LCA will run a Criminal Records Check at least one time in any twelve
month period and reserves the right to run additional periodic checks as long as I have a
child enrolled at LCA
PrintedName
Signature
Date of
Place of Birth
Birth
Social Security Number
Today's Date
First Name
First
(OtherNames)
Street Address
Telephone Number
Middle
Name
Last Name
Last Name (Other Names, Maiden)
Middle
City
Date of Birth
List all other cities where there has been residency:
County
Age
State Zip
Sex (lvVF)
Lakeland Christian Academv
397 S. Stemmons Freeway
Lewisville, TX 75067
972t219-3939
FAX: 972-219-9601
PARffi ITT/AD
ULT EMAR.GEi{CY
IVIED TCAL
F'ORIV{/RELEASE OF LIABXT,ITY
ParenVAdult
Name:
Parent/Adult
Birth date:
Address:
City:
State:
Home
Phcne:
Work
Dl"^-^,
r 11u11!.
zip:
Pager
^- rr^tt.
UI
\-UII.
ParenVAdult
Emergency Contact:
ParenVAdult Emergency Contact Phone:
This authorizes Lakeland Christian Academy to obtain immediate medical care and
consents to the hospitalization of, the performance of necessary diagnostic test upon, and
the use of surgery should an emergency occur. It is also understood that this agreement
covers only those situations which are true emergencies and/or the above mentioned
person cannot be reached for consent.
Please complete the
l.
2.
following for yourself (parenVadult volunteer):
Iiwe will be responsible for payment of medical expenses.
Medical treatment costs are covered by:
Insurance Company:
Policy #:
Flospital:
Physician:
Pre-existing medical conditions:
RELEASE OF LIABILITY
I do hereby and discharge Lakeland Christian Academy, Lakeland Baptist Church
it's agents or representatives from liability for any and all present or future claims
and
regarding personal or bodily injury to said participant which might result from or be
sustained during participation in this activity.
Signature
Date