Excelsior

12217 Spring Valley Parkway

Victorville, Ca.92395

760.245.4262

Field Trip Waiver & Medical Authorization

I hereby give my permission for my child, to participate in the

field trip. Held on

Trip Details: Students must bring money for food

Students will be excluded from field trip if this form is not complete

I fully understand that my child is to abide by all rules and regulations governing conduct during the field trip. It is understood that any child determined to be in violation of these behavior standards may be sent home at the parent or guardians’ expense. I understand and acknowledge that by consenting to allow my child to participate in this field trip, I shall, by law be deemed to have given up all claims against Excelsior and each of its officers, employees and agents (hereinafter collectively referred to as “Excelsior”) for any injury, accident, illness or death occurring during or by reason of the field trip. I also agree to relieve the district of any responsibility for damage to or loss of my child’s property occurring during or by reason of the field trip.

Whenever possible, attempts will be made to contact the parent/guardian prior to taking any medical action.In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child. It is understood that the resulting expenses will be the responsibility of the parent(s), guardian(s), or participant.

Special Note to Parents/Guardians: Remember, Excelsior does not carry student accident insurance

___Check here is there are NO special needs that the staff should be aware of and NO medication requiredon this trip.

___Check here if the child named above has special medical needs.

Excelsior

12217 Spring Valley Parkway

Victorville, Ca.92395

760.245.4262

  • Kindly attach a description detailing the needs of the student, Please include any information you feel important for the staff to be aware of while on the trip.
  • All medication must be registered on this form
  • All medication, except those that must be kept on the student’s person for emergency use, must be kept and distributed by the staff.
  • Listall medicationstobe taken by the student here: Include the name of prescription and dosage information

Prescription Name / Dosage Information

Excelsior

12217 Spring Valley Parkway

Victorville, Ca.92395

760.245.4262

Emergency Contact/Insurance Information
Heath Insurance Company / Date
Policy # / Home Address:
Parent Signature
Student Signature
Parent/Guardian Information / Home #
Cell #
Work #
In the event of illness or accident and if unable to contact above, please contact:
Name & relationship to student / Home #
Cell #

SIGNATURE REQUIRED FOR FIELD TRIP PARTICIPATION

Facilitator Academy ChairMy signature affirms that the above student is in good academic standing and his/her attendance is current.