Field Trip Permission/emergency Information printable pdf download

SAN JUAN UNIFIED SCHOOL DISTRICT

FIELD TRIP PERMISSION/EMERGENCY INFORMATION

School Name____________________________Teacher’s Name ____________________________________

Field Trip Destination _____________________________________________________

Departure Date_____________Time________am/pm Return Date________________ Time _______ am/pm

_____

TRANSPORTATION:

Walking _____Private Vehicle (Volunteer Drivers) ______District _______ Commercial

INFORMATION: Education Code Section 35330 authorizes the governing board of any school district to conduct field trips or

excursions for students in connection with courses of instruction of school related social, educational, cultural, athletic or school band

activities to and from places in the state, any other state, the District of Columbia, or a foreign country. Field trips or excursions may

be connected with such courses of instruction or such school activities that further the student’s education and participation is

voluntary. As a voluntary event, no special attendance credit is given for participation, and an alternative activity at school will be

provided if my child does not participate.

PARENT/GUARDIAN TO COMPLETE EMERGENCY INFORMATION:

Student_____________________________________________ Parent/Guardian_______________________________

Home #____________________________ Work #______________________ Cell #___________________ _______

PLEASE CHECK THE APPROPRIATE STATEMENT REGARDING STUDENT’S HEALTH:

____ My child has no known health problems.

____ My child has the following health problems:______________________________________________________

_______________________________________________________________________________________

(Please identify any medication that the child may need during the course of this trip.)

PLEASE CHECK #1 OR #2 BELOW TO INDICATE DESIRED ACTION IN THE EVENT OF ACCIDENT OR

EMERGENCY:

____ 1. In the event of accident or emergency, when a parent/guardian is unavailable, I hereby authorize a representative of the

school to make such arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary

transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment of my

child as he/she considers necessary. In the event said physician is not available at any time, I authorize such care and treatment to be

performed by any licensed physician or surgeon. THE UNDERSIGNED PARENT/GUARDIAN FULLY UNDERSTANDS

HE/SHE IS RESPONSIBLE TO PAY ALL COSTS INCURRED AS A RESULT OF THE FOREGOING. If your child is

injured on a field trip, contact Risk Management at (916) 971-7756 for a claim form.

Physician’s Name_________________________________________ Phone #_________________________________

Medical Insurance Name (Kaiser, etc.)________________________ Medical #___________________________ ____

____ 2. I do not choose the above statement and desire the following action to be taken:_________________________

_______________________________________________________________________________________________

WAIVER:

California law provides as follows: “All persons making the field trip or excursion shall be deemed to have waived all

claims against the district or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip

or excursion.” (Education Code Section 35330) I acknowledge that as a condition of my child’s participation, I agree this waiver of all

claims shall be extended to any and all claims against the school, its employees and volunteers, the district, its governing board, the

individual members thereof, and all other district officers, agents and employees. Further, I agree to indemnify and hold harmless the

school, its employees and volunteers, the district, its governing board, the individual members thereof, and all other district officers,

agents and employees for any injury, harm, accident, illness, death, loss, liability, cost, expense or claim of any type whatsoever

(including attorney’s fees) or damage to personal property occurring during or by reason of this excursion/field trip or event.

I understand that participation in this field trip involves a certain degree of risk. I have carefully considered the risk involved and

consent for my child to participate in the field trip.

My signature below authorizes my child to participate in the field trip:

PARENT/GUARDIAN SIGNATURE___________________________________ DATE_________________________

(

Original Form to be carried by person transporting student.)

Teacher to return original form to school office after field trip.

Field Trip Permission/emergency Information

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