Parent Consent For Voluntary Field Trip/excursion And Emergency Medical Authorization Form - Fresno Unified School District
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1FRESNO UNIFIED SCHOOL DISTRICT
Parent Consent for Voluntary Field Trip/Excursion and Emergency Medical Authorization
To the Principal of________________________________ Student’s Name:_______________________________ID#____________
(School)
(Student’s Name & ID #)
has my permission to participate in the field trip/excursion to _________________________________________________________
on _______________________________________. Departure________________A.M./P.M. Return______________A.M./P.M.
LUNCH
METHOD OF TRANSPORTATION
Pupil will be at school during lunch
Walking
Pupil should bring sack lunch without liquid
School Bus
Other:_____________________________
Private Auto
Other____________________________________
PARENTS PLEASE NOTE:
It is necessary that parents specifically authorize their child to be included in this field trip/excursion. While supervision for this event
will be furnished by the school, parents are hereby advised that such supervision by school personnel will occur only during the time
period started above. Although the school district will take every precaution to assure the welfare and safety of your child while
participating in this activity, it is important you understand the school district assumes no liability whatsoever in case of injury of
accident. It is also important for the student and the parent/guardian to realize that injuries or accidents can occur and occasionally
they can be catastrophic. Catastrophic means permanent, serious injury such as paralysis-partial or total, or even death. Further, I
have been advised of the contents of the State of California Education Code Section 35330 which states in part: “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.”
__________________________________________________________________
_______________________________________________
Approval Signature (Parent/Guardian)
Date
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _
(N0TE: TEACHERS DETACH HERE AND TAKE BOTTOM PORTION ON THE FIELD TRIP)
Should it be necessary for my child to have emergency medical treatment while participating in this trip. I hereby authorize Fresno
Unified School District to use their judgment in obtaining emergency medical service for my child. I further authorize any individual
selected by Fresno Unified School District personnel to render such emergency medical treatment to my child as he/ she may deem
necessary and appropriate. I understand that the Fresno Unified School District has no district insurance, which pays the medical, or
hospital or any other costs that might be incurred on behalf of my child. Consequently, I understand that any and all such costs shall be
my sole responsibility. The Fresno Unified School District has previously made available to me student insurance which can be obtained at
my own expense.
Emergency Medical Authorization
(Parent/Guardian Please Complete)
___________________________________________
___________________________________________
(Signed)
Student’s Name and I.D. #
Parent, Guardian or Participating Adult
_________________________________________________
Address
_________________________________________________
Home Telephone Number
_________________________________________________
Business Telephone Number
_________________________________________________
Emergency Telephone Number
PLEASE CHECK HERE IF SPECIAL INSTRUCTIONS REGARDING MEDICAL TREATMENT ARE ON FILE IN THE SCHOOL
NOTE:
This form must be completed for participating in all field trips conducted by Fresno Unified School District within the State of California.
G:\fusd.fresnounified.org\dept\riskmgmt\Documents\Permission-Slip-2-6-2012.doc
39500P6161842 3M
06/28/07
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