Las Positas College
Student Field Trip/Excursion Waiver and Medical Authorization Form
Instructions for Chaperone(s): Have all students complete this form. Carry forms during the entire field trip or excursion. At conclusion,
submit forms to the sponsoring entity or division office. Forms will be kept on-file for at least one full calendar year from date of return.
Student’s Name: _________________________________________ Student ID #: W___________________________________________
Address: ___________________________________________ ____ Telephone #: _____________________________________________
_______________________________________________
Title of Field Trip or Excursion: _____________________________ Destination: _____________________________________________
Name of College Sponsoring Entity: ____________________________________________________________________________________
Start Date and Time: _____________________________________ Return Date and Time: _____________________________________
“All persons making the field trip or excursion shall be deemed to have waived all claims against the [Chabot-Las Positas Community College
District and any college district employee or representative] for injury, accident, illness, or death occurring during or by any reason of the
field trip or excursion. All adults taking out-of-state field trips or excursions and all parents or guardians of minor students taking out-of-
state field trips or excursions shall sign a statement waiving such claims.”
(Source: California Code of Regulations, Title 5, Section 55220)
The student agrees to notify the chaperone of any limitation or accommodation that may be required to participate in the field trip or
excursion prior to the commencement of the activity. Furthermore, any medical prescription, medical treatment, allergies, or illness must
be shared with the chaperone prior to the field trip or excursion. Documentation may be required.
In the event of illness or injury, the student, if unable to make a decision due to being unconscious and decisions need to be made
immediately, consents to x-ray examinations, anesthetic, medical, surgical, emergency medical transportation, hospital care or dental
diagnosis or treatment from a licensed physician, surgeon, or dentist as deemed necessary for the student’s safety and welfare. The
student understands that resulting expenses may be his/her responsibility. Please initial one - I do consent _____. I do not consent _____.
The student agrees to abide by all rules and regulations governing their conduct during the field trip or excursion as defined by Las Positas
College student conduct code and any additional rules and regulations of the sponsoring entity. Furthermore, the student agrees to
participate in all field trip or excursion activities unless excused by the chaperone, remain with the group at all times, adhere to all
applicable federal and state laws including the consumption of alcohol, drugs, or other illegal substances regardless of age, adhere to
curfew, and any additional restrictions decreed by the chaperone. Individuals not associated with the college or ineligible to participate in
the field trip or excursion may not participate in any sponsored activity.
Any violation of the rules and regulations may result in the student being sent home prior to the conclusion of the field trip or excursion at
his/her expense, forfeiting participation in all field trip or excursion activities, and/or being subject to student disciplinary action upon
return to the college including, but not limited to, suspension or recommendation for expulsion from the Chabot-Las Positas Community
College District including Chabot College and Las Positas College.
By signing below, I/we hereby certify that I/we have read and fully understand the above notice and do hereby give my/our consent for the
student to participate in the field trip or excursion.
Student Signature: _____________________________________________________________ Date: ____________________________
Parent/Guardian Print and Sign Name: _____________________________________________ Date: ____________________________
Required if the student is under the age of 18 as of the commencement date and time of the field trip or excursion. Confirm age with student participants.
In the event of accident, illness, or emergency, please notify: _______________________________________________________________
Relationship to student: _____________________________________ Telephone #: _____________________________________
Medical Insurance Carrier: ___________________________________ Policy #: _________________________________________
Optional information but may be needed if the student is unable to make a decision due to being unconscious and decisions need to be made immediately.
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