Voluntary Field Trip Notice And Medical Authorization Form printable pdf download

Palm Springs Unified School District

Voluntary Field Trip Notice

And Medical Authorization

Dear Parent/Guardian,

Please complete and return to __________________________________________________.

My son/daughter ______________________________________________ has my permission

to participate in the following voluntary activity.

Destination:___________________________________________________________________

Departure Date & Time: _________________Return Date & Time:____________________

Transportation: School Bus ___________School/Employee automobile:_________________

In the event of illness or injury, I give my 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 understand that I hold the Palm

Springs 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/GuardianSignature:______________________________________Date:___________

Address:_____________________________________________Phone:_________________

Student Signature:_______________________________ Date of Birth:________________

Medical Insurance Carrier: ______________________Policy Number:_________________

Address:_____________________________________________________________________

(1) If your son/daughter has a special medical problem, kindly attach a description

of that problem to this sheet.

(2) ________Check here if any medication(s) is required on this trip.

(3) Medication(s) must be registered on this form and must have prior physician

authorization (obtained at school); please list here name of medication(s) and

reason___________________________________________________.

(4) All medications must be kept and distributed by staff, excepting those which

must be kept on the student’s person for emergency use and with prior

authorization only.

Revised 1/9/14

Voluntary Field Trip Notice And Medical Authorization Form