No student will be permitted on the Field Trip unless this completed and signed Authorization is submitted to the Supervising Teacher, Sponsor, or Sch...0 downloads 1 Views 256KB Size
SOLANO COUNTY OFFICE OF EDUCATION
STUDENT 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.
School: Home/Cell/Work Telephone: Parent/Guardian Name: (Best way to reach you during trip) Emergency Contact & Telephone No. (other than parent): Field Trip Destination: Field Trip Date:
Expected Departure Date/Time Expected Return Date/Time: Method of Transportation: Supervising Teacher/Sponsor: Physician’s Name: Physician’s Address & Phone: Medical Conditions/Medications: Medical or Patient ID Number: FOOD SERVICE: Is a sack lunch required for this activity? (Sponsor, please check) Yes No Parents: If a sack lunch is required (7 day notice) for this activity, they are available through Food Service or you may bring your own sack lunch. Yes – I would like to order a sack lunch from the cafeteria (payment** must be attached to this permission form) My student has a Peanut Allergy No – I will send a sack lunch from home with my student (**Federal Lunch Program rules and procedures remain in place for sack lunch requests)
PRINCIPAL’S SIGNATURE: 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-County Office of Education ("COE") 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 COE 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 COE, 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 COE 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. 5. The suggested contribution is the COE’s estimated cost for your student to participate in this field trip. No student will be excluded from the field trip due to an inability to contribute toward such costs. Please contact the supervising teacher or the school office for more information. Contributions may be received by the supervising teacher or the school office.
Parent/Guardian Printed Name Date Received by School:
Date 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