Please Note: This form must be completed, signed, and returned to your child’s teacher BEFORE yourchild can be permitted to attend any fieldtrip.

Deadline Date: Student should return this completed form by
Part 1 – to be completed by Teacher:
Destination:
Date of Field Trip: / Teacher:
Time of Departure: / am / pm / From:
Time of Return: / am / pm / Place
Approximate time of arrival at School Campus / am / pm
Field Trip Transportation: / Bus / Walk / Volunteer Driver* / Other
Yes No Special Clothing / If yes, which type:
Yes No Admission Donation / Fee (not required) / Amount:
Yes No Transportation home after field trip Yes No Sack Lunch
Comments:

Part 2: To be completed by Parent/GuardianPlease do not detach

Student’s Name: Grade: ______

Parent’s Name: ______Parent’s Phone # during Day: ______

If field trip goes beyond school hours, my son/daughter:

 Has my permission to walk home, or

 Will be provided transportation home by: ______Phone: ______

 I authorize photographs for news or press release purposes, as well as publication of my student’s name for such purposes

PERMISSION: The above-named student has my permission to participate in the above-named field trip and to be transported AS PROVIDED BY THOSE IN CHARGE. In accordance with Education Code Section 35330, I the parent/guardian, hereby waive all claim against the San Jacinto Valley Academy, SJUSD, or the State of California for injury, accident, illness, or death occurring during or by reason of this field trip. Under school and facility supervision, my son/daughter must stay within the field trip facilities at all times. Failure to follow any school for facility rule will result in school disciplinary action and the loss of further school and field trip privileges.

MEDICAL EMERGENCY: I hereby authorize any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care deemed advisable by any physician, dentist, and/or surgeon licensed under the provisions of the Medical Practice Act or Dental Practice Act. This authorization is effective on the date of the field trip shown above.

The following MUST be completed (Please print legibly)

Family Doctor: ______Doctor’s Phone #: ______

List student’s allergies, medications, etc.: ______

MEDICATION: My son / daughter MAY/ MAY NOT (circle one) receive prescribed medication during this trip.

If YES – medication on field trip: Type: ______Dosage: ______Time: ______

Parent/Guardian Signature: ______Date: ______

Field Trip Permission Slip/9/13/2018/dh