Science Field Trip Permission Slip

Sierra Unified School District

FOOTHILL MIDDLE SCHOOL PARENT CONSENT FOR VOLUNTARY FIELD TRIP AND EMERGENCY MEDICAL AUTHORIZATION This form must be completed and returned to school before student is allowed to attend this trip. Students must be eligible in order to attend. If the student fails to abide by school rules or regulations, he/she could be subject to discipline and removal from the activity.

Field Trip Information Class/Organization:_____8th grade Science______________Teacher’s Name:_____Boele_______________________ Destination:_____CSU Fresno___________________Purpose:__Science field trip (planetarium, sports facility)______ Date:__11/19/08________ Time Depart FMS:_9:00______Time Return FMS_2:30______ Overnight: yes____no__X__ Lunch needed: yes_X*__no_____(see back of form) Walk_____Van_____Bus__X__Private_____

Transporation:

*Students can bring money to buy lunch at CSUF

Parent Permission I,__________________________________give permission for ________________________________ to attend this field (Please print parent/guardian name)

(Please print student name)

trip. While supervision for this event will be furnished by the school, parents are hereby advised that such supervision by school personnel will occur only during the time period stated above. I understand that the school district will take every precaution to assure the welfare and safety of my child while participating in this activity and I understand that the school district assumes no liability whatsoever in case of injury or accident.

I understand that if my child returns to the school grounds after normal school hours, it is my responsibility to provide for his/her transportation from that point. I acknowledge the school district will not be responsible for, nor provide my child transportation home from the school grounds. Date:______________ Signature:_______________________________________________ Parent/Guardian

Phone:___________________________ Contact number for that day

Student Responsibility I am aware that as a representative of FMS School Student Body, I must conduct myself so as to reflect credit upon the school at all times and I will obey all rules and regulations of this trip.

Date:______________ Student Signature:___________________________________

Other Arrangements I, ____________________________________, hereby relieve the State of California, the Sierra Unified School District, its agents, employees and officers of any responsibility they might have to transport my child, ___________________, from the site of the above described field trip to ___________________________. I instruct the school district to entrust my child to the custody of _______________________, who will transport my child from the field trip. I assume full responsibility for any and all risks of bodily injury to my child which may occur as a result of my child’s not being transported by the school district. If for any reason the

school district cannot comply with my instructions, my child will be transported back to the school grounds. Date:___________________ Signature___________________________________ Parent/Guardian

Please Complete Medical Information on Back Medical Information ________________________________ AUTHORIZATION

EMERGENCY MEDICAL

(Student’s Name)

(Parent/Guardian please complete)

Should it be necessary for my child to have emergency ___________________________________ medical treatment while participating in this trip, I hereby Parent/Guardian authorize Foothill Middle School personnel to use their judgment in obtaining emergency medical services for my ___________________________________ child. I further authorize any individual selected by Address Foothill Middle School personnel to render such emergency medical treatment to my child as he/she may deem necessary ___________________________________ and appropriate. I understand that the Foothill Middle School Home/Cell Phone has no district insurance which pays the medical or hospital costs that might be incurred on behalf of my child. Consequently ___________________________________ I understand that any and all such costs shall be my sole Business Phone responsibility. The Foothill Middle School has previously made available to me student insurance which can be obtained at ___________________________________ my own expense. Additional Contact/Emergency Numbers ___________________________________ Health Insurance Carrier & Policy #

_______CHECK HERE IF SPECIAL INSTRUCTIONS REGARDING MEDICAL TREATMENT ARE ON FILE IN THE SCHOOL OFFICE.

Cafeteria Sack Lunch Order Sack lunches will be provided for students at the same cost as hot lunch. Sack lunch includes the following:

Sandwich, Chips, Veggie Sticks, Fruit, Cookie, and Milk.

_____My child will purchase a cafeteria lunch with milk cash _____My child will purchase mile only _____ _____My child will bring a sack lunch from home

_____from account _____from _____from account _____from cash

Please note or comment on any allergies or special needs your child has on the line below. __________________________________________________________________________________________________