To be completed by parent/guardian and collected/maintained by trip organizer
Murrieta Valley Unified School District
VOLUNTARY EXCURSION/FIELD TRIP PERMISSIONAND MEDICAL AUTHORIZATION – Grad Night

Dear Parent/Guardian:

Kindly complete and return this form to   Hawk Rock/ Bookkeeper	
(teacher / person in charge of trip)

I hereby authorize (student’s name)	to participate in voluntary off-campus
field trips/excursions, to Grad Night, May 26-27, 2022.

It is extremely important to be aware of any medical condition/problem and/or medications a student is required to take when going on a field trip. Please list any medical conditions and/or medications that we should know about.

Any student who needs to take medication while on a field trip MUST have written permission from both the parent and the physician, as well as provide the medication in the original, labeled container. A staff person must keep the medication with them at all times unless previous arrangements have been made (i.e.: student has written permission on file to carry medication, such as an asthma inhaler).

*If your student already has medication at school that they take on a daily basis, you may contact the Health Office and arrange, prior to the field trip, for their medication, along with the permission forms to be sent on the field trip. If you do not contact the Health Office, it will be assumed they will not be taking their medication on trip unless you make other arrangements.

Phone Number

Date

 	   	

 	_ Physician Signature

Time(s) of Administration

Dose

Name of Medication

**Fill out this section ONLY IF student needs to take medication during field trip **

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 are considered necessary in the best judgement 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.

As stated in California Education Code Section 35330, I agree to hold Murrieta Valley Unified 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.

By my signature below, I acknowledge the highly contagious nature of COVID-19 and voluntarily assume the risk of becoming exposed to or infected by COVID-19 and accept sole responsibility for any injury to my child(ren), myself or my family (including, but not limited to, personal injury, disability, and death) and shall defend, indemnify and hold harmless the Murrieta Valley Unified School District, its Board, officers, agents and employees against any and all claims, demands, losses, damages, court costs, attorney fees, expenses, or costs of any kind or character, as it relates to COVID-19.

I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violation of these rules and regulations may result in that individual being sent home at the expense of his/her parent/guardian.

Parent/Guardian Signature: 		Date:  	

Address: 		Phone:  	

Student’s Birth date: 	

Medical Insurance Carrier: 		Subscriber’s ID # :  	

Emergency Contact: 		Phone:   	

Rev. 3/2021