EMERGENCY INFORMATION
Name of Class: _______________________________________________________________
Destination: ___________________________________________________________________
Departure Date & Time: _______________ Return Date & Time: ________________________
As stated in California Education Code Section 35330, I understand that I waive all claims
against the District, its officers, agents and employees for any injury, accident, illness, or
death occurring during or by reason of this field trip or excursion, including acts of
negligence by the District, its officers, agents or employees.
In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical,
surgical or dental diagnosis or treatment and hospital care from a licensed physician and/or surgeon as
deemed necessary for my safety and welfare. It is understood that the resulting expenses will be the
responsibility of the participant.
Signature: _____________________________ Date: __________________________________
Address: _______________________________ Phone: _________________________________
_____________________________________________________________________________
Medical Insurance Carrier Policy No. Address
In the event of illness or accident, please notify the following individuals:
_____________________________________________________________________________
Name Address Phone
_____________________________________________________________________________
Name Address Phone
If there are any special medical problems, kindly attach a description of the problem to this sheet.
click to sign
signature
click to edit
![]()
