Visit Chico State University

Western Sierra Field Trip

Parent Permission Form

TO WHOM IT MAY CONCERN:

I hereby grant permission for______to participate in a field trip or activity to:

Activity Name & Location Address: Bodega Bay Research Center

Students will be traveling to the ocean on an OVERNIGHT FIELD BIOLOGY EXPERIENCE and collecting samples with graduate students with the Eisen Lab (microbial research team) led by Jenna Morgan Lang, PI.

Students will stay in Bodega Bay Research Center Dorms and FIVE Chaperones will be present.

Location Phone: 530-575-8866 (Dixon Cell Phone)

Sponsored by (Dept./Teacher): AP Biology Teacher Beth Dixon/UC Davis Eisen Lab Winogradsky Outreach Citizen Science Team

Leaving from: WSCA Parking Lot 7:30 a.m. FRIDAY

Returning to: WSCA Parking Lot9:30 p.m. SATURDAY

Times / Event
7:30am / Depart WSCA for Bodega Bay
10:00-11:30am / Tour of Bodega Bay Marine Center
11:30-12:30pm / Brown Bag Lunch
1:00-4:00pm / UC Davis Winogradsky Outreach Research
6:30pm / Hot Dog Roast Dinner
9:30 PM / Lights Out (UC Davis Research Dorms)
7:00 AM-5:00 PM / Hands-on Research with UC Davis Professors and Eisen Lab Scientists at Bodega Bay (lunch and dinner provided)
6:30 PM / Depart for WSCA
9:00 PM / Return to WSCA

I understand that all students participating in this trip will be responsible in conduct to the driver and to the teachers or adult sponsors at all times. It is further understood that students are required to go to and return from this event on the transportation provided, unless prior arrangements have been made. Authorization to treat a minor: In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the school staff to secure proper treatment for my student,______.

I understand that Education Code Section 35330 provides that all persons making a field trip or excursion shall be deemed to have waived all claims against the school or the State of California for injury, accident, illness or death occurring during or by reason of the field trip or excursion, and I therefore acknowledge that as a condition of my son/daughter participating in the said activity, I waive any and all claims against the Western Sierra Collegiate Academy for injury, accident, illness, or death occurring during or by reason of the participation in said activity.

I understand this trip is optional, and attendance by my child is not required.

I UNDERSTAND THAT BY SIGNING BELOW I AM GIVING PERMISSION FOR MY STUDENT TO PARTICIPATE IN THE FIELD TRIP, AND I AM GIVING MEDICAL AUTHORIZATION.

______

Parent / Guardian SignatureDate

RETURN THIS FORM BY: September 30, 2013 to Ms. Dixon by 4 p.m.

PLEASE SEE CONTINUATION OF FORM ON BACK

Western Sierra Field Trip

Contact Information & Medical Authorization

Parent’s Name: ______Home Phone: ______

Work Phone: ______Cell Phone: ______

If unable to reach parent, other authorized adult: ______

Relationship: ______Phone: ______Alternate Phone______

Physician’s Name: ______Phone: ______

Insurance Carrier’s Name: ______Policy #:______

Special medical considerations regarding my student (Example: allergies to medicine, food, etc.):

______

If this field trip involves a water activity, my student’s swimming ability is:

□Non-Swimmer□Beginner□Intermediate□Advanced

If you are fingerprinted and available to drive for the above described field trip, please read and sign the following:

□Yes, I have fingerprint clearance, and am available to chaperone and my vehicle is insured.Driver’s Application must be on file. □I have______seats in my vehicle.

Transportation for the activity will be provided by:

□Private Vehicle□Other (please specify:______)

If private vehicles are used, I give permission for my student to (check all that apply):

□Ride with parent□Ride with teacher or WSCA designee.

(I understand that this is a school-sponsored trip, and all CA Ed Code, Penal Code, Civil laws, school rules, and guidelines apply.)

Parent Drivers/Chaperones: In compliance with vehicle code section 16451, I possess an owner’s policy of motor vehicle liability insurance of at least the amount required by law. I further certify that my automobile meets the safety standards of the California Highway Patrol. Driver Application Form including proof of insurance must be on file at the school.

Parent/Guardian Signature______Date______

If private vehicles are used, the Driver Application Form MUST be completed.

Revised 5/10 - JA