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STUDENT PERMISSION FORM
Norwalk-La Mirada Unified School District
12820 Pioneer Blvd.
Norwalk, CA 90650
PARTICIPATION IN VOLUNTARY SCHOOL SPONSORED ACTIVITY
PARENT PERMISSION, ASSUMPTION OF RISK
School __LA MIRADA HIGH SCHOOL______Date_October 17th, 2016
Student’s Name______has permission to participate in the following school sponsored activity: UCLA Bruin Model United Nations Conference/Competition
Nature of Activity: Students interested in competing in the Saturday, November 12th and Sunday, November 13th, 2015, 8:00 a.m. to 4:30 p.m. (appx. time) conference at UCLA campus, located at 405 Hilgard Ave., 90095, must research, write a position paper and a 1-5 minutes General Debate speech - refer to http://www.bruinmun.org/bruinmun/novice/ for more information on novice (DUAL DELEGATES ONLY), intermediate and advanced committee choices and committee chairs. Students must choose one out of 5 committee choices.
Special Instruction/Information: Mr. John Alvarez, LMHS teacher and Mr. Jose Martinez, have been completely vetted and approved by Norwalk La Mirada USD (fingerprinted, DMV and vehicle insurance documents examined) can transport 4 students (first come, first served) and will stay throughout the event. Beyond the first 4 students riders, other interested students will have to acquire their own personal transportation and make their own arrangements. If parents wish to ONLY drop off students and ONLY pick up students, Mr. John Alvarez and Mr. Jose Martinez, will supervise students and be available for medical emergencies. On November 12th and November 13th, meet Mr. Alvarez OR Mr. Martinez, in front of the school flagpole at 6:30 a.m. At approximately 5:00 p.m. students will be returned to the LMHS flagpole (in front of the school office, on Adelfa Drive) and must be picked up by the parents/guardians of the students who rode with Mr. Alvarez and/or Mr. Martinez. Note that Ms. Williamson will NOT be in attendance. Please wear conservative business attire. Conference registration is $70.00 per delegate (covers conference supplies, awards and food) and a $45.00 donation will be greatly appreciated. The school MUN Club will pay the remainder of the conference delegate’s fee. Please enclose student donations (EXACT CASH ONLY) in an envelope, with complete student name, UCLA MUN Conference printed on front of envelope and signed permission slip by MONDAY, OCT. 24th to Mrs. Williamson, Room #464. If you would like Mrs. Williamson to look over your General Debate Speech, submit to her no later than Friday, Nov. 4th via school email at
Be sure to attend lunch MUN/EP Club meetings every Monday, for paper assistance, speech practice and last minute reminders. Keep a second copy of this permission form for instructions.
Person in charge: Ms. Norma Williamson, LMHS Teacher, MUN Advisor and Drivers: Mr. John Alvarez, and Mr. Jose Martinez, LMHS Teachers.
In the event of illness or injury, I do hereby consent to whatever x-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment, hospital care and emergency transportation considered necessary in the best judgment of the attending physician, surgeon or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.
I fully understand that participants are to abide by all rules and regulations governing conduct during this activity. As provided for in California Education Code 35330, I agree to waive all claims against the district and hold the 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. This waiver shall not apply to any occurrences, which may arise solely out of the negligence of the District, its employees or agents.
______Work Phone ( )______
(Signature of Parent/Guardian) (Please Print Name) Home Phone ( ) ______
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(Date) (Student’s Signature)
Family Medical Insurance Carrier:______Policy #:______
In an emergency contact______Work Phone:( )______
(Name) (Relationship) Home Phone :( )______