Student Participation In District-Sponsored Voluntary Field Trip Parental Permission, Assumption Of Risk, And Medical Treatment Authorization Form
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1BERKELEY UNIFIED SCHOOL DISTRICT
STUDENT PARTICIPATION IN DISTRICT-SPONSORED VOLUNTARY FIELD TRIP
PARENTAL PERMISSION, ASSUMPTION OF RISK, AND
MEDICAL TREATMENT AUTHORIZATION
Date __________________________________
Student's Name: ______________________________ has permission to participate in the following field trip:
_
_____________________________________________________________
Destination/Nature of Activity
_
(Please be specific, e.g., Concert at UCLA.)
Special Instructions:___________________________________________________________________________________
(e.g., Bring sack lunch.)
Departure
Return
Date: ___________________
Time: ________________
Date: _____________
Time: _________________
Person in Charge: _______________
Position: _____________
School: _____________________
Type of Transportation:
District Bus/Vehicle
Walking
Other:___________________________
Health or special needs: Check as appropriate.
My student has no special health needs the staff should be aware of, and no medication is required
on the trip.
My student has a special need, and instructions are attached.
Number of attached
pages:________.
Other:
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 and emergency transportation considered necessary in the best judgment of the
attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital
or facility furnishing medical or dental services.
I fully understand that participants are to abide by all rules and regulations governing conduct during the trip.
As provided for in California Education Code Section 35330, I agree to waive all claims against the Berkeley Unified School
District (District) and hold the 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. This waiver shall not apply to any occurrences
which may arise solely out of the negligence of the District, its employees or agents.
_____________________________ _____________________________
Work Phone (
)___________
Signature (Parent/Guardian)
(Please Print Name)
Home Phone (
) ___________
_________________________________________
________________________________________________
Student’s Date of Birth
Student’s Signature
Family Medical
InsuranceCarrier:___________________________________________________
Policy Number:__________________
(e.g., Blue Cross, HealthNet, Kaiser)
In the event of an emergency, please contact:
__________________________
____________________________________
Work (
) ___________
(Name)
(Relationship)
Home (
) ___________
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