Cypress Ridge High School Key Club
Sponsored by the Cy-Fair Kiwanis Club
Membership Requirements:
30 Key Club hours per semester (60 hours total per year)
- Must have 20 PHYSICAL hours (physical volunteering) and 10
NONPHYSICAL hours (donations, meeting attendance, etc.)
$25 dues (includes club shirt)
Regular Meeting Attendance
Failure to meet these requirements will result in probation for up to one month. The member
will be contacted by their class representative and be told that he/she can remain a member
by becoming active in the club (attending meetings, completing hour requirements, etc.).
Failure to do so will result in the person’s name will be taken off the attendance sheet and
terminated due to failure to meet requirements of membership. As a parent, I understand
that I am responsible for getting my student to events.
Name
Home Address
City Zip T-Shirt Size
Email
Cell Phone Graduation Year
Date of Birth / / Gender
New or Returning Member
Student Signature
Parent Signature
For Officer Use Only: ㅁ Paid ㅁ Input in Database
Medical Authorization Form
I/We, being the parent(s) or legal guardian(s) of ____________________ a minor do hereby appoint
_______Sponsors________ of Cypress Ridge Key Club, Houston Texas to act in my/our
behalf in authorizing emergency medical, dental, or surgical care and hospitalization for the
above-named minor during a period of my/our absence on the 2017-2018 school year .
(Date)
This document shall be presented to a physician, dentist, or appropriate hospital
representative at such time as emergency medical, dental, surgical care, or hospitalization
may be required.
Hospitalization coverage for the above-named minor:
________________________ ________ ________________________ _________
Signature Parent/Guardian Date Signature of Parent/Guardian Date
If different:
________________________________ _________________________________
Street Address Street Address
_________________________________ _________________________________
City State Zip City State Zip
________________________ _________ ________________________ _________
Witness Date Witness Date
_____________________________________________________________________________
Name of Insurance Company or Government Carrier
______________________________________ _______________________________________
Identification or Contract Number Family Physician's Name
_______________________________________
Family Physician's Phone Number
Insurance Waiver Statement:
Where no proof of insurance is established, parents of students must assume legal
responsibilities for expenses incurred for injuries to students that occur at school on co-
curricular activities. I have read and understand the insurance waiver statement.
___________________________ _________ _________________________ _________
Signature Parent/Guardian Date Signature Parent/Guardian Date
_______________________________________ ___________________________________
Student's Name Class Period
Parent Permission Slip
___________________
Date
I hereby grant my son/daughter/ward ____________________________________________________
Student’s Name
my permission to attend and participate in any and all activities which are a part of
the Cypress Ridge High School Key Club instructional field trip.
School Name
I understand that the class and instructional field trip activities will be supervised by adult
leaders. I hereby release the CYPRESS-FAIRBANKS INDEPENDENT SCHOOL DISTRICT and all its
supervisors, employees, and/or representatives from any and all liability and/or claims and/or
cause of actions, individually or collectively, for any damages or injuries which might be received
during class activity, on field trips or in traveling to and from such field trip destinations, except
for those for which the School District, its supervisors, employees, and/or representatives do
have effective insurance coverage-- but only to the extent of such insurance coverage.
___________________________________________
Parent/Guardian Signature
___________________________________________
Address, City, State, Zip Code
___________________________________________
Telephone number where you may be reached
during the field trip
I understand that any misconduct (by school authority standards) on my part will result in non-
participation in future activities and that severe misconduct might result in my parent being called
to come and remove me from an instructional field trip activity.
Parent Information: Medication Request
If your child will be requiring medication during the field trip, you must supply the nurse with an
empty prescription bottle with the proper dosage information on the label. The nurse will put one
dose of the medication in the bottle for the field trip. Please complete the following information.
I request that the following medication be administered to my child __________________________
during the field trip.
Name of Medication: __________________________________________________________________
Dosage: ____________________________________________________________________________
Time: ______________________________________________________________________________
____________________________ ___________
Signature of Parent/Guardian Date
If your child is on medication at school, but you do not want the medication administered during
the field trip, please notify the school nurse.
