VAL VERDE UNIFIED SCHOOL DISTRICT
School
975 West Morgan Street Perris, CA 92570
(951) 940-6100
VOLUNTARY EXCURSION/FIELD TRIP NOTICE
MEDICAL AUTHORIZATION/TEACHER AUTHORIZATION
Dear Parent/Guardian: (Please complete and return signed form to your
child/s teacher.) My son/daughter has my permission to participate in the
following voluntary activity:
Name of Student
Grade
DESTINATION: First Annual RVHS Young Men's Youth Leadership Conference at RVHS
DEPARTURE:
RETURN:
7:45
2:00
AM
SCHOOL BUS
PUPIL SHOULD BRING SACK LUNCH
✔
OTHER
PRIVATE AUTO
Breakfast and lunch provided by RVHS
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
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.
California Education code Section 35330 provides, in pertinent part, as
follows:
“all persons making the field trip or excursion shall be deemed to have waived all
claims against the District or the State of California for injury, accident, illness or
death occurring during or by reason of the field trip excursion.”
I have read and understand Education Code Section 35330. I further understand
that I hold harmless the Val Verde Unified School District, it officers, agents and
employees, from any and all liability or claims which may arise out of or in
connection with my child’s participation in this activity.
Organizing Teacher
Class
PARENT/GUARDIAN
2
Date
Street Address
Work Phone
City, State, Zip
Home Phone
INSURANCE CARRIER INFORMATION
Mr. Juan Santos/Mrs. Aguirre
The following teachers by signing this form are allowing the student to
attend a field trip and excuse them from attending class on that date.
The student is responsible for all assignments.
1
Parent/Guardian Signature
OTHER NA
TO BE COMPLETED IF FIELD TRIP IS
DURING SCHOOL
Rancho Verde High School
Field Trip Excuse from Class Permission Form
I further agree that I waive all claims against the District for injury or death resulting
from the trip(s).
Teacher signature
Grade
OK to go
3
4
5
6
7
Family Medical Insurance Carrier
Street Address
City, State, Zip
WALKING
PUPIL WILL BE AT SCHOOL DURING LUNCH
AM
PM
METHOD OF TRANSPORTATION
LUNCH
PM
Date: March 7, 2015
Policy Number
As the parent/guardian of my child, I give permission for my
child to miss their classes on the date(s) listed above. I realize
that my son/daughter is responsible for missed assignments.
A special note to Parents/Guardians: All medications must be registered on this
form. All medications must be kept and distributed by the staff.
*parents must check one the following boxes
Parent/Guardian Signature
Date
Administrator Signature
Date
Check here if your son/daughter does not require special treatment or care by the staff.
Check here if your son/daughter does require special treatment or care by the staff. List
below the special treatment or care required.
Check here if there is any medication which must be taken or used by the student.
Mr. Juan Santos/Mrs. Aguirre
Teacher sponsoring trip
COMPLETE BACK SIDE OF FORM
VOLUNTARY ACTIVITIES PARTICIPATION FORM
ACKNOWLEDGEMENT AND ASSUMPTION OF POTENTIAL RISK
________________________________________wishes to participate in the District-sponsored
trip/activity to _________________________________________________________________.
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, which may result from
participating in these activities; include, but are not limited to, the following:
1. Sprains/strains
2. Fractured bones
3. Unconsciousness
4. Head and/or back injuries
5. Paralysis
6. Loss of eyesight
7. Communicable diseases
8. Death
I understand and acknowledge that participation in these activities is completely voluntary and
as such is not required by the District.
As stated in California Education Code Section 35330, I understand that I hold the Val Verde
Unified School District it is officers, agents and employees harmless from any and all liability
or claims, which may arise out of our connection with my child’s participation in this activity.
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.
I acknowledge that I have carefully read this VOLUNTARY ACTIVITIES PARTICIPATION FORM
and that I understand and agree to its terms.
Student Signature
Date
Parent/Guardian Signature
Date
Address
Phone
A signed VOLUNTARY ACTIVITIES PARTICIPATION FORM must be on file at the District Office before a
student will be allowed to participate in the above extra-curricular/co-curricular activities.