MUROC JOINT UNIFIED SCHOOL DISTRICT

STUDENT PARTICIPATION IN VOLUNTARY FIELD TRIP/EXCURSION

PARENTAL PERMISSION, ASSUMPTION OF RISK, AND EMERGENCY MEDICAL TREATMENT AUTHORIZATION

Under Education Code section 35330(d), persons making a School District sponsored field trip or excursion are statutorily deemed to have "waved" all claims against the District arising out of any injury, illness, or death occurring during or by reason of the field trip or excursion.

Student's Name:_____________________________________   Date:___________________

The above named student has permission to participate in the following voluntary field trip/excursion:

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Special Instructions (e.g. bring sack lunch, jacket, closed toe shoes required, etc.):

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Departure Date:______________________ Time:_______ Return Date:__________ Time:_________

Type of Transportation: ? District Bus   ? District Passenger Vehicle   ? Walking   ? Other___________________

Health or Special Needs:

? 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.

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 is considered necessary in the best judgment of the attending physician, surgeon, or dentist.

I understand and acknowledge that these activities, by their very nature, pose the potential risk of serious injury/illness to individuals who participate in such activities.

I understand and acknowledge that some of the injuries/illnesses that may result from participating in these activities include, but are not limited to, the following:

I understand and acknowledge that participation in these activities is completely voluntary and as such is not required by the District for course credit or for completion of graduation requirements.

I understand and acknowledge that in order to participate in these activities, I and my son/daughter agree to assume liability and responsibility for any and all potential risks that may be associated with participation in such activities.

As provided for in California Education Code section 35330, I agree to waive all claims against the 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.

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Signature (Parent/Guardian) Print Name Contact Phone Number

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Addition Contact Information