PACIFIC COLLEGIATE SCHOOL

VOLUNTARY FIELDTRIP /EXCURSION NOTICE

AND MEDICAL AUTHORIZATION – ADULT CHAPERONE

Dear Chaperone,

Please complete this form and return to the School office.

Destination:____

Departure Date & Time: __Return Date & Time:

As stated in California Education Code Section 35330, I understand that I hold Pacific Collegiate School, its officers,agents and employees, and the State of California harmless from any and all liability or claims for injury, accident, illness or death which may arise out of or in connection with my child's participation in this activity.

In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical,surgical or dental diagnosis or treatment and hospital care from a licensed physician and/or surgeonas deemed necessary for my safety and welfare. It is understood that the resulting expenses will be my responsibility.

Printed Name:

Signature: ______Date: ______

Address:

Phone: ______

Medical Insurance Carrier:

Medical Insurance Carrier Policy Number:Medical Insurance Carrier Phone Number:

In the event of illness or accident, please notify:

Name:______Day phone:

Evening Phone:Cell phone:

Address:

If you have any special medical problems, attach a description of the problem to this sheet, or list here:

Pacific Collegiate School Chaperone Agreement

If agreement has been reached with the supervising teacher, volunteers may chaperone students on this trip who comply with all the following requirements:

  1. Chaperones must be responsible adults above the age of majority and approved by the field trip/excursion coordinator and the Principal. Chaperones are responsible for the supervision of students at all times.
  1. For overnight trips, if the adult is not the parent/guardian of a child in the school engaging in the field trip, the adult must get a criminal background clearance. This includes all coaches. A criminal background clearance is obtained via fingerprinting done through the School Administrative Office. Prospective chaperones must contact the Admin Office to arrange. Results are returned from the Department of Justice in approximately one week.
  1. Chaperones must be familiar with the School’s Field Trip/Excursion Policy and must sign below indicating that they have read and agreed to follow the School’s policies and procedures prior to supervising students.
  1. Chaperones must ensure that no adults or students partake of any alcohol or other illegal substances.
  1. There will be no smoking on the part of chaperones or students, including students who have reached the age of majority. This rule will be in force at all times.
  1. Chaperones on overnight trips are responsible for ensuring that the students abide by the set curfew time, and are not roaming, creating noise or infringing on the rights of others.
  1. Chaperones who are driving must submit the Personal Vehicle Use forms to the person in charge of the field trip/excursion prior to transporting students on any trip.

I have read and understand the foregoing and agree to the terms as stated above.

Name:

Signature:

Date:

Principal:

Signature:

Date:

Pacific Collegiate School, a CaliforniaPublicCharterSchool

Form revised 11/1/2003Page 1 of 2