Medical Form

  •  E 6153 (c)

     

     

     

    VOLUNTARY EXCURSION/FIELD TRIP NOTICE AND

    MEDICAL AUTHORIZATION - MINOR

     

    Dear Parent/Guardian:

     

    Please complete and return this form to:     Mr. Justin K Witt – El Diamante High School.

    My son/daughter _____________________________________________ has my permission to participate in the following voluntary activity:                 EDHS School Sponsored Choir Trips 2015-2016              .

     

    Destination:                          Various                         Transportation Provided By: Visalia Unified Schools

     

    Departure Date:                   Various                        Departure Time:                                  Various                

     

    Return Date:                         Various                         Return Time:                        Various                

     

    As stated in California Education Code Section 35330, I understand that I hold Visalia Unified School District, its officers, agents and employees harmless from any and all liability or claims, which may arise out of or in connection with my child’s participation in this activity.

    “Education Code Section 35330 states in part: “The governing board of any school district or the county superintendent of schools of any county may: (a) Conduct field trips or excursions in connection with courses of instruction or school related social, educational, cultural, athletic, or school band activities to and from places in the state, any other states,...or a foreign country...A field trip or excursion to and from a foreign country may be permitted to familiarize students with the language, history, geography, natural sciences, and other studies relative to the district’s course of study for such students, pupils... (b) Engage such instructors, supervisors, and other personnel as desired to contribute their services over and above the normal period for which they are employed by the district, if necessary, and provide equipment and supplies for such field trip or excursion.”

     

    “...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 any injury, accident, illness or death occurring during or by reason of the field trip or excursion.  All adults taking out-of-state field trips or excursions and all parents or guardians of pupils taking out-of-state field trips or excursions shall sign a statement waiving such claims.”

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    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.

     

    ______________________________________________________________________________________________________

    Medical Insurance Carrier                                               Policy No.                                     Address

     

    (___) Check here if there are no special problems that the staff should be aware of and no drugs are required on the trip.

    A special note to Parent/Guardian: (1) All medications must be registered on the form; (2) All medications, excepting those which must be kept on the student’s person for emergency use, must be kept and distributed by the staff; (3) If any medication or drugs are to be taken by student, list them below:

     

    Name of Drug:  __________________________________      Time Drug must be taken:______________________

     

    Reason: _________________________________________________________________________________________.

    If your son or daughter has a special medical problem, kindly attach a description of that problem to this sheet.

     

    I fully understand that participants are to abide by all rules and regulations governing conduct during the trip.  Any violations of these rules and regulations may result in that individual being sent home at the expense of his/her and/or parent/guardian.

     

    Parent/Guardian Signature: _______________________________________              Date: _______________________________

    Address: _____________________________________________________               Phone: _____________________________

    Student Signature: ______________________________________________              Date of Birth: ________________________

    1/26/2009

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