Version 02052010

TRIP WAIVER, MEDICAL INSURANCE AND EMERGENCY CARE PERMISSION

This form must be returned to the sponsor/coach before the student is permitted to participate.

Activity:________________________________ Sponsor/coach:___________________________

1. Waiver

I/We understand and hereby, authorize, appoint and empower the Shanghai American School to take any
action it deems appropriate for the benefit of the student in case of an unavoidable and/or unforeseeable
accident, emergency medical need, or surgical service if a parent or guardian cannot be reached to make
decisions. In doing so, the Shanghai American School will not be held liable for giving such authorization.
In addition, it is agreed to promptly reimburse and indemnify the Shanghai American School for any sums
incurred as a result of the Shanghai American Schools giving such authorization of obtaining medical care.
Therefore, as a condition to the Shanghai American Schools acceptance of the student for trip, we hereby
waive and agree to waive any and all claims that we may have against the Shanghai American School, its
employees, board members, officials, and/or any individual members associated with the Shanghai
American School.

2. Medical Insurance

The Shanghai American School does not provide personal insurance for individual students. Personal
medical/health insurance is the responsibility of each family. We strongly encourage all families to provide
such insurance for their children; or to be self-insured.

I hereby acknowledge that the responsibility to provide adequate personal medical/health insurance lies
directly with the family

3. Emergency Care Permission

In the event that my child has an accident or illness while attending the Shanghai American School or on
authorized field trips or activities outside the school, the chaperones/nurses will make every reasonable
effort to contact me or my spouse or other emergency contact prior to medical treatment or hospitalization.
If hospitalization is required, any procedures, surgery, or anesthesia that may be necessary to save the life
of my child, may be done via phone consent or my spouse or other emergency contact.

If reasonable efforts to contact myself, my spouse and other emergency contact person are unsuccessful, the
Shanghai American School and its designated chaperones/nurses are authorized to:

Take my child to seek medical/dental care
To consent any procedure, surgery, or anesthesia, if, in the judgment of the medical staff, such
treatment is needed to save of the life and treat the emergency medical conditions of my child
Fill in and sign the forms and other documents necessary to facilitate the above medical procedure;
and
Incur and pay any medical, hospital and ambulance expenses on my behalf as a result of such
injury or illness, including those may not be covered by insurance.

_________________________
Name of the Student
_________________________ ________________________ _______________
Name of Parent/Guardian Signature of Parent/Guardian Date