LANDMARK MIDDLE SCHOOL Procedure No.21.2

MORENO VALLEY UNIFIED SCHOOL DISTRICT
VOLUNTARY EXCURSION/FIELD TRIP WAIVER
AND MEDICAL AUTHORIZATION

Dear Parent/Guardian,

Please complete and return this form to:_Mr. Rose, Landmark Middle School. Rm. G-118__

______________________________ has my permission to participate in the following voluntary activity:

Destination:__Astrocamp, Idyllwild, CA 92549_________

Departure Date & Time:_March 27, 2001 , 9:00 A.M.    Return:  March 29, 2001, Approx.3:00 P.M__

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 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 of facility furnishing medical or dental services.

As stated in California Education Code Section 35330, I understand that I hold Moreno 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.

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 his/her parents' expense.

_____________________________________________________________________________________________
Signature of Parent/Guardian Date

_____________________________________________________________________________________________
Address Phone

_____________________________________________________________________________________________
Signature of Student Date of Birth

_____________________________________________________________________________________________
Family Insurance Carrier Policy Number

______________________________________________________________________________
Address

SPECIAL NOTE TO PARENTS/GUARDIANS:

1) All drugs must be registered on this form

2) All drugs, excepting those which must be kept on the student's person for emergency use, must be kept and distributed by the staff.
3) (____) Check here if there are No special problems that the staff should be aware of and No drugs are required on the trip.
4) If any medication or drugs ARE to be taken by the student, list them here. Name of drug and reason: _________________ _________________________________________________________________________________________________

IF YOU SON OR DAUGHTER HAS A SPECIAL MEDICAL PROBLEM PLEASE ATTACH DESCRIPTION OF THAT PROBLEM TO THIS SHEET.