Participation Of District Volunteer In Field Trip Activity Assumption Of Risk And Medical Treatment Authorization Form
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1BERKELEY UNIFIED SCHOOL DISTRICT
PARTICIPATION OF DISTRICT VOLUNTEER IN FIELD TRIP ACTIVITY
ASSUMPTION OF RISK AND
MEDICAL TREATMENT AUTHORIZATION
Name:___________________________________________________________________________________
Destination/Nature of Activity: ________________________________________________________________
(Please be specific, e.g., Attend concert at UCLA.)
Purpose of Your Attendance: _________________________________________________________________
(Chaperone, etc.)
Departure
Return
Date: _____________________ Time: ______ ___________ Date: ______________________
Time: ______________
Method of Transportation:
School Bus/Vehicle
Walking
Other: ___________________
As provided for in California Education Code Section 35330, I agree to hold the Berkeley Unified School District ("District"),
its officers, employees and agents harmless from any and all liability and claims arising out of or in connection with my
participation in this activity. This waiver, however, shall not apply to any injuries or damages that arise solely out of the
negligence of employees or agents of the District.
In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental or surgical
diagnosis and/or treatment, emergency transportation and hospital care from a licensed physician and/or surgeon as
deemed necessary for my safety and welfare. It is understood that the resulting expenses will be the responsibility of the
participant.
________________________________________________________________
______________________________
Signature
Date
___________________________________________________________
Work (
) _______________
Address:
Number
Street
Home (
) ______________
____________________________________________________________
City
State
Zip Code
Health Insurance Company: ______________________________
Policy Number: ______________________
(e.g., Kaiser)
In the event of illness or accident, please notify:
Name:__________________________________________________
Relationship: ______________________
____________________________________________________
Work Phone (
) ____________________
Address:
Number
Street
_____________________________________________________
Home Phone (
)_____________________
City
State
Zip Code
If there are any special medical instructions, kindly attach an explanation to this sheet.
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