PARTICIPATION IN VOLUNTARY FIELD TRIP FORM 3204-1

CONSENT, ASSUMPTION OF RISK AND EMERGENCY MEDICAL AUTHORIZATION (This form must be completed for participation in all field trips conducted by the CUSD)

The following voluntary field trip has been authorized by (school): 	

Overnight Trip:	Yes	No	Out-of-State Trip:	Yes	No

Specific Location: 	

Description of Field Trip: 	

Day(s)/Date(s): 	 Departure:	 AM/PM	Return:	 AM/PM

School Person in Charge: 	 Position: 	

LUNCH
Student will be at school during lunch Participant should bring sack lunch/drink*
Other 	

METHOD OF TRANSPORTATION Walking	Private Vehicle School Bus	Charter Bus
Airplane (commercial)	Other 	

*See Authorization section
**Parent/Guardian Permission for Transporting Student in Private Vehicle is included.

A donation	A transportation fee	in the amount of $	for this field trip is suggested.

The participant may be exposed to the following high risk activities during this field trip/activity:	

AUTHORIZATION: (Please return this form to the school person in charge listed above)

Participant Name:	
Minor Student	Adult Student	Volunteer/Chaperone

I hereby authorize the above-named individual to participate in the field trip outlined above.

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 and 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 further acknowledge that the District does not provide medical coverage for participants in this activity.

I fully understand that participants are to abide by all rules and regulations governing conduct.

I acknowledge that although the field trip may not be considered a high-risk activity, participants may be exposed to the high-risk activity(ies) listed above during this trip.
Special instructions regarding emergency medical treatment for the above-named individual are on file in the school office. (Please refer to the Emergency Card located in the school office.)
*IF APPLICABLE: I need Campus Catering to provide a sack lunch for the above-named participant. (Students will be charged according to their status in the National School Lunch Program. Other participants will be charged the full amount.)

I wish to volunteer as a chaperone and understand that I must also complete Form 9212-1, Volunteer Application, and meet the requirements of Board Policy No. 9212.

I have read and completed the waiver on Page 2.

Approval Signature (Parent or Guardian/Adult Student/Volunteer)	Printed Name	Date

Medical Insurance Carrier (i.e., Blue Cross, Kaiser):	 Policy Number: 	

Printed Name of Emergency Contact

Other Phone Number

Form 3204-1

Relationship to Participant

Other Contact Person

Phone Number

Phone Number

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PARTICIPATION IN VOLUNTARY FIELD TRIP FORM 3204-1(continued)

WAIVER OF CLAIMS

All adults and adult students taking part in a field trip and all parents/guardians of minor students taking field trips are required to sign a statement waiving such claims.

Waiver by Parent/Guardian of Minor Student

I certify that I am the parent/guardian of the student identified below. As provided for in California Education Code Section 35330, I agree to waive all claims against the Clovis Unified School District (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.

Student Name:	

Parent/Guardian Signature:	 Date:	

Waiver by Adult Student

As provided for in California Education Code Section 35330, I agree to waive all claims against the Clovis Unified School District (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 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.

Printed Name:	

Signature:	 Date:	

Medical Authorization and Waiver by Adult Accompanying Student on Trip (Volunteer/Chaperone)

As provided for in California Education Code Section 35330, I agree to waive all claims against the Clovis Unified School District (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 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.

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 and 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. It is understood that the resulting expenses will be the responsibility of the participant.

Special medical instructions, if any: 	

Printed Name:	

Signature:	

Adopted: 3/24/10

Form 3204-1

Date:	

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