Parent Permission For School Sponsored Activity

And Consent to Medical Treatment

Please complete both top and bottom oI Iorm

(Name oI Student) has the opportunity to participate in a school
activity away Irom school premises. II you approve the Iollowing arrangement, please sign at the bottom
oI this section and return to the Iaculty sponsor.

NATURE OF ACTIVITY
DESTINATION
DATE TIME OF DEPARTUREDATE/TIME OF RETURN
TRIP SUPERVISIOR
MEANS OF TRANSPORTATION: (Sponsor please check)
A. District-owned bus
B. Commercial (Name oI company)
C. Other (SpeciIy)
I understand the nature oI the school activity in which my son/daughter will be participating and that
he/she is expected to abide by all school regulations during the course oI the activity.

I understand that, pursuant to education Code 44808, the district is liable or responsible Ior the conduct or
saIety oI my son/daughter only while he/she is or should be under the immediate and direct supervision oI
an employee oI the district.

I hereby give my permission Ior him/her to participate in the above-described activity.

I Iurther agree that, in the event oI an accident, illness or any other circumstance requiring medical
treatment, such treatment may be procured Ior my son/daughter without Iinancial obligation to the district.

Date: Signature oI Parent/Guardian
IMPORTANT MEDICAL INFORMATION THE SUPERVISOR SHOULD KNOW:

EMERGENCY TELEPHONE NUMBERS:
THIS FORM SHOULD BE KEPT BY THE CHAPERONE DURING THE ACTIVITY
(Please complete the Iorm below)

AUTHORIZATION TO TREAT A MINOR
I (We), the undersigned parent, parents or legal guardian oI , a minor, do hereby authorize
and consent to any x-ray examination, anesthetic, medical or surgical diagnosis and treatment and emergency hospital
care which is deemed advisable by an is to be rendered under the general or special supervision oI any member oI the
medical staII and emergency room staII licensed under the provisions oI the Medicine Practice Act and on the staII oI
any acute general hospital holding a current license to operate a hospital Irom the State oI CaliIornia Department oI
Public Health. It is understood that eIIort shall be made to contact the undersigned prior to rending treatment to the
patient, but that any oI the above treatment will not be withheld iI the undersigned cannot be reached.
This authorization is given pursuant to the provisions oI Section 25.8 oI Civil Code oI CaliIornia.

Date: Signature oI
Father and/or Mother, or Guardian
Allergies to Drugs or Foods

Date oI last Tetanus Toxoid Booster
PLEASE COMPLETE BOTH TOP AND BOTTOM OF FORM