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Field Trip Permission Slip Fillable

This document is a permission slip and waiver of liability for a voluntary field trip. It provides details of the trip such as date, location, purpose, transportation, and contact information. It requires a parent/guardian signature to give permission for their child to attend and to authorize emergency medical treatment if needed. The parent also waives all claims against the school in the event of injury or illness during the trip. If swimming is involved, additional permission and liability waiver is required.

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112 views1 page

Field Trip Permission Slip Fillable

This document is a permission slip and waiver of liability for a voluntary field trip. It provides details of the trip such as date, location, purpose, transportation, and contact information. It requires a parent/guardian signature to give permission for their child to attend and to authorize emergency medical treatment if needed. The parent also waives all claims against the school in the event of injury or illness during the trip. If swimming is involved, additional permission and liability waiver is required.

Uploaded by

tvtcf286v9
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Voluntary Excursion / Field Trip Permission /

Medical Authorization and Waiver of Liability

To: Parent/Guardian
From:___________________________________ Site_____________________________________________
On _________________________ the ____________________________ class will go on a field trip to
_________________________________________________________________________________________.
Purpose of trip: _____________________________________________________________________________
Transportation will be by:  District Bus  District Van  Charter Bus  BART  Walking
 Train  Airplane  Private Vehicle  Other____________
Departure Time_________ Return Time __________ This trip  will  will not include swimming

Written permission and a waiver of liability from the parent or guardian must be on file for each student attending this
trip. Kindly complete this form and return it to the school. This field trip is voluntary; your child is not required to attend. If
your child does not attend, alternate activities will be provided to him or her at school. Thank you.
I hereby give my permission for ______________________________________________ to participate in this
voluntary activity: First (Please print) Last Grade
In the event of illness or injury, I do hereby authorize the activity supervisor to consent to whatever emergency medical,
surgical or dental care is considered necessary in the best judgment of the attending physician, surgeon, or dentist. I agree
to pay for such medical care whether or not the costs are insured by my health insurance. I understand that an attempt will
be made to contact me, by phone if possible, before such care is administered. Phone number(s) where
parent(s)/guardian(s) can be reached on the day of the trip____________________________________________
Emergency medical contact: Physician:___________________________ Phone Number:_____________________
My child  does  does not have medication on file with school office. Medical Record or Insurance #___________
I understand that participants in this field trip are to abide by all rules and regulations governing conduct during the field
trip and that any violation of these rules and regulations result in my child being sent home at his or her and/or my
expense.
If swimming activities are part of this trip, complete this portion of the form: I  give  do not give permission for my
child to participate in swimming activities on this trip. I further hold harmless and waive all claims and liability against the
Lammersville Elementary School District, its officers, agents, employees, and volunteers, for injury, accident, illness, or death
occurring or by reason of my child’s participation in the swimming activities on this field trip. My child’s swimming ability can
be described as follows: _______________________________________________________
Pursuant to California Education Code, section 35330, I hereby hold harmless and waive all claims and liability against the
Lammersville Elementary School District, its officers, agents, employees, and volunteers, for injury, accident, illness, or death
occurring during or by reason of this field trip.

I understand that if I or another parent / guardian of my child voluntarily chooses to transport only my child to / from
the field trip, that it is a voluntary activity undertaken by me; it is not District-sponsored transportation, and is subject
to the waiver of liability and other immunities under law. I agree that if I transport other LUSD pupils I will follow all
LUSD policies and procedures. I have read, understand, and agree to all the provisions stated above. I give my
permission for my child to participate in this voluntary activity.
 I would like to purchase a school bag lunch for my child.
Parent/Guardian Name (Please print) _____________________________________________________________
Address: ____________________________________________ City:___________________________________
Phone: _________________________________________________ Date: _____________________________
Signature of Parent/Guardian: __________________________________________________________________

111 S. De Anza Boulevard (209) 836-7400


Mountain House, CA 95391 Fax (209) 836-7402

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