IUSD EXCURSION/FIELD TRIP WAIVER AND MEDICAL AUTHORIZATION- MINOR
THE FORM BELOW IS ONLY FOR PARENTS TO READ-- PLEASE DO NOT TRY TO 'FILL OUT THIS SECTION'. THIS IS FOR READING AND INFORMATION PURPOSES ONLY.
THE INFORMATION WILL VARY BASED ON THE FIELD TRIP
HARDCOPY FOR PARENT/GUARDIAN SIGNATURE WILL BE SENT HOME WITH THE STUDENTS- THIS ONLINE FORM WILL BE USED TO COLLECT INFORMATION, BUT WILL NOT BE USED IN PLACE OF PARENT'S PHYSICAL SIGNATURE)
SAMPLE VERSION OF IRVINE UNIFIED SCHOOL DISTRICT
EXCURSION/FIELD TRIP WAIVER AND MEDICAL AUTHORIZATION - MINOR
(Education Code Section 35330)
Name of School: University High School
I hereby give my permission for my child, _______(SAMPLE COPY DO NOT FILL IN)___________, to participate in the________(SAMPLE COPY DO NOT FILL IN)_______________ field trip as a part of his/her regular school program. This trip is to be held from _____________________, 20 ____ through ____________________, 20 ____.
I fully understand that my child is to accept all rules and requirements governing conduct during the field trip. It is understood that any child determined to be in violation or unfulfilling of these behavior standards will be sent home at the parents’ expense. I, the undersigned, hereby release and discharge the Irvine Unified School District, officers, employees, agents and servants (herein) collectively referred to as “District”) from all liability arising out of or in connection with the above described field trip or excursion. For the purposes of this agreement, liability means all claims, demands, losses, causes of action, suits, or judgments of any and every kind that I, my heirs, executors, administrators or assignees may have against the District because of any death, personal injury or illness, or because of any loss or damage to property that occurs during the above described field trip or excursion and that results from any cause other than the negligence 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 or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child. It is understood that the resulting expenses will be the responsibility of the parent(s) or
_________________ (PROVIDED AS HARD COPY) _________________________
Signature of Parent or Guardian Signature of Student
__________________(SAMPLE COPY DO NOT FILL IN)___________________________________
Address Phone Number
_____________(SAMPLE COPY DO NOT FILL IN)________________________________
Health Insurance Company Policy Number
In the event of illness or accident and if different from above, please contact:
_______________(SAMPLE COPY DO NOT FILL IN)_________________________
Name: Address Phone
SPECIAL NOTE TO PARENTS/GUARDIANS:
(1) All drugs must be registered on this form; (2) all drugs, excepting those which must be kept on the student’s person for emergency use, must be kept and distributed by the staff; (3) check here if there are NO special problems that the staff should be aware of and NO drugs are required on the trip; (4) if any medication or drugs are to be taken by student, list them here:
(2) If your son daughter has a special medical problem, please attach a description of the problem to this sheet.
Name of drug and reason:
______________(SAMPLE COPY DO NOT FILL IN)______________________________________________
_______________(SAMPLE COPY DO NOT FILL IN)_____________________________________________
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