*To be completed by parent/guardian and collected ...
*To be completed by parent/guardian and collected/maintained by teacher/trip organizer*
VOLUNTARY EXCURSION/FIELD TRIP PERMISSION
AND MEDICAL AUTHORIZATION – MINOR
Dear Parent/Guardian:
Please complete and bring this form with you to the Bookkeeper.
I hereby authorize (students name) to participate in the following activity:
Description (e.g. “Field trip”): Senior Trip
Destination: Cal Adventure Grad Night
Departure date & time: May 31, 2019 @ 1:00pm Return date & time: June 1, 2019 @ 4:00am
In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.
As stated in California Education Code Section 35330, I agree to hold Murrieta Valley Unified School District, its officers, agents and employees harmless from any and all liability or claims which may arise out of or in connection with my child’s participation in this activity.
I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violation of these rules and regulations may result in that individual being sent home at the expense of his/her parent /guardian.
Parent/Guardian Signature: ___________________________________________ Date:
Address: Phone:
Student’s Date of Birth:
Medical Insurance Carrier: Subscriber’s ID #:
Special notes to Parent/Guardian:
All medications must be registered on this form
All medications, except those which must be kept on the student’s person for emergency use, must be kept and distributed by the staff
If any medication or drugs are to be taken by student, list them here:
If your son or daughter has a special medical problem we should be aware of, kindly attach a description of that problem to this sheet.
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