Student Field Trip Authorization - Twin Rivers Unified School District
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1Student Field Trip Authorization
No student will be permitted on the Field Trip unless this completed and signed Authorization is submitted to the Supervising Teacher, Sponsor, or
School Main Office at least 48 hours prior to Field Trip. Verbal Authorizations, or Authorizations not on this form, cannot be accepted.
Student Name:
Address
:
(Street/POB)
Grade:
DOB:
Address
:
(City/Zip)
School:
Home Telephone:
Emergency Contact & Telephone No.:
Field Trip Destination:
Date of Trip:
Expected Departure Time:
Expected Return Time:
Method of Transportation:
Supervising Teacher/Sponsor:
Medical Conditions/Medications:
By signing below, I acknowledge and agree as follows:
1.
Participation in this Field Trip is voluntary and is a privilege. I understand that the student has the right and ability to remain at school instead of
participating in the Field Trip. I request that the Student be allowed to participate in the Field Trip, under the supervision of the Supervising
Teacher/Sponsor and/or adult chaperones, with transportation to be provided in the described manner (which may include transportation in non-
District owned/operated vehicles).
2.
California Education Code Section 35330 states that: “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.” I
understand and agree that I cannot hold the District, its officers, agents, or employees liable for any claim arising out of, or which is in some
manner connected with, the Student’s participation in this Field Trip. [Adults participating in out-of-state Field Trips must also sign a statement
waiving such claims.]
3.
The Supervising Teacher or Sponsor will discuss Field Trip rules and safety requirements with students and adult chaperones prior to the Field
Trip, which may include dangerous or hazardous conditions or circumstances exposing the Student to potential harm or injury, potentially
including death. Students are required to obey all rules and safety requirements of the Field Trip, as well as Codes of Conduct and general
standards for respect of persons and property and good behavior. I understand and agree that failure of the Student to follow Field Trip rules or
safety requirements may result in the Student being sent home, at my expense, and that the Student may be barred as a result from future Field
Trips.
4.
Emergency medical information regarding the Student is on file with the District and is current. (Provide updated information before the trip, if
necessary) If an injury or medical emergency occurs during the Field Trip, a Supervising Teacher, Sponsor or chaperone has my express
permission to administrator or to authorize the administration of urgent or emergency care, including the transportation of the Student to an
urgent care or emergency care provider. In such circumstances, notice to me and/or the Emergency Contact of the injury or medical emergency
may be delayed. Therefore, any urgent or emergency care provider has my express authority to conduct diagnostic or anesthetic procedures,
and/or to provide medical care or treatment (including surgery), as they may deem reasonable or necessary under all existing circumstances.
All costs and expenses associated with such care are solely my responsibility.
____________________________________
________________________________________
__________________
Signature of Parent/Guardian
Printed Name
Date
Date Received by School: _____________________________
Received by: ______________________________________________
Supervising Teacher/Sponsor shall take a copy of this form on the Field Trip/The original Form will remain on File with the Main Office
for a period of no less than one (1) year after the date of the Field Trip
Rev. 07.01.08
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