Di xie Elementary School, 1175 Idylberry Drive, San Rafael, CA 94903 (415) 492-3730
FIELDTRIP PERMISSION FORM
DATE OF ACTIVITY_________________ LOCATION_________________________________
Students will be traveling by: BUS______ PRIVATE VEHICLE _____
Departure from School_____________ Arrival Back at School ______________
STUDENT'S NAME _________________________ GRADE _____ BIRTHDATE _____________
SPECIAL HEALTH CONDITION/S (be very specific): _________________________________
Allergies (environmental and/or drug): __________________________________________
Medication/s: ____________________________________ Asthma: __________________
Please circle best contact phone # on the date of field trip:
PARENT/GUARDIAN'S NAME ____________________________ HOME: __________________
ADDRESS __________________________________________ WORK:___________________
PERSON/S (OTHER THAN PARENT) TO NOTIFY IN CASE OF EMERGENCY:
I, the parent/guardian of the above named student hereby give my permission for his/her participation in the voluntary activity named above.
As stated in California Education Code Section 35330, and attested to by my signature below, I understand that all persons making the field trip or e xcursion shall be deemed to have waived all claims against the district (Dix ie School District) or the State of California for injury, accident, illness, or death occurring during, or by reason of, the field trip or excursion. I understand, therefore, that I hold the Dix ie School 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.
In the event of illness or injury, I do hereby consent to whatever x-ray, ex amination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.
PARENT/GUARDIAN'S SIGNATURE___________________________ DATE _______________