VOLUNTARY EXCURSION/FIELD TRIP NOTICE
MEDICAL AUTHORIZATION – MINOR
Dear Parent/Guardian:
Kindly complete and return two signed copies of this form to ______________________________.
____________________________has my permission to participate in the following voluntary activity:
_____________________________________________________________________________
Destination:____________________________________________________________________
Departure Date & Time: _________________ Return Date & Time:_______________________
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 are considered necessary in the best judgment of the attending physician,
surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or
facility furnishing medical or dental services.
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.
I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any
violation of these rules and regulations may result in that individual being sent home at the expense of his/her
parent/guardian. The Parent/Guardian will be held responsible for any damages caused by the above
mentioned student.
Parent/Guardian Signature: _______________________ Date: _____________________
Address: ___________________________________ Phone: __________________
Student Signature: ____________________________ Date of Birth: _________________
________________________________________________________________________
Medical Insurance Carrier Policy No. Address
A special note to Parent/Guardian: (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 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:
Name of drug and reason) __________________________________ if your son or daughter has a special medical
problem, kindly attach a description of that problem to this sheet.
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