Excel Academy Permissions Slip and Authorization Form

VOLUNTARY FIELD TRIP AUTHORIZATION AND RELEASE OF LIABILITY
Name of Field Trip*
Date of Field Trip*

MonthDayYear
Date
How many Excel Academy Students will be attending this Event?*
Student 1 Name*

First NameLast Name
Student 1 Grade*
Student 1 Teacher of Record (ToR)*
Student 2 Name*

First NameLast Name
Student 2 Grade*
Student 2 Teacher of Record (ToR)*
Student 3 Name*

First NameLast Name
Student 3 Grade*
Student 3 Teacher of Record (ToR)*
Student 4 Name*

First NameLast Name
Student 4 Grade*
Student 4 Teacher of Record (ToR)*
Parent 1 Name*

First NameLast Name
Parent 2 Name

First NameLast Name
Parent 1 Email*
example@example.com
Parent 2 Email
example@example.com
Parent 1 Phone Number*
Please enter a valid phone number.
Parent 2 Phone Number
Please enter a valid phone number.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Special Accommodations: Please list any allergies/medical conditions
Field Trip Authorization, Waiver, and Release of Liability
I authorize my child/student to participate in the above-described field trip. I acknowledge that my child’s/student’s participation in this field trip is not required by Excel Academy Charter School (the “Charter School”), or any teacher or employee of the Charter School and is voluntary. I understand that in determining that participation in this field trip has educational value, the Charter School has not investigated or approved its safety, the qualifications or financial responsibility of any person or firm involved in the field trip, or the facilities or equipment that may be used.

In addition, the Charter School shall not provide or approve transportation to or from this field trip. All participants are expected to secure their own transportation to and from the field trip destination.

I hereby waive, release and discharge the Charter School, its employees and agents, and the State of California from any and all claims for damages or personal injury, accident, illness, death, or property damage occurring during or by reason of the field trip. I acknowledge and understand that the field trip may involve an element of risk and/or danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.

I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS RELEASE OF LIABILITY IS A CONTRACT BETWEEN MYSELF AND THE CHARTER SCHOOL. My signature below authorizes my student to participate in this field trip and my agreement to the terms of this agreement, waiver, and release. By signing below I represent that I have the authority to sign this form on behalf of any minor(s) listed above.
Parent 1 Signature*

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Parent 2 Signature

Clear

Emergency Medical Information and Consent
Name of Primary Physician

First NameLast Name
Primary Physician Phone Number
Please enter a valid phone number.
Medical Insurance Company
Coverage Number
Known Allergies
Medications Current being Administered (including time and dosage required)
In the event of accident or emergency during or by reason of the field trip when immediate medical care is necessary, I hereby give my consent to the Charter School to authorize any emergency medical treatment or hospital care for my child/student considered necessary on the advice of any physician, surgeon, dentist or
medical care practitioner. It is understood that an effort shall be made to contact the above-listed parent/guardian prior to the rendering of any treatment. It is also understood that an effort shall be made to contact the child’s/student’s physician identified above, but that treatment may be performed by another licensed physician or surgeon, dentist or medical care professional. I, AS THE UNDESIGNED PARENT/GUARDIAN, FULLY UNDERSTANDS I AM FULLY RESPONSIBLE TO PAY ALL COSTS THAT MAY BE INCURRED AS A RESULT OF THE FOREGOING.

If my child is injured at a field trip, I understand that I can contact the Charter School at 949-387-7822

By signing my name below, I hereby acknowledge my intent to sign this Voluntary Field Trip Authorization and Release of Liability, and affirm all of the above.
Parent 1 Signature*

Clear
Parent 2 Signature

Clear

Field Trip Parent/Guardian Participation and Release of Liability
Will you, as a Parent/Guardian, be attending this Field Trip with your student?*

YesNo
Parent Name

First NameLast Name
Parent Email
example@example.com
Phone Number
Please enter a valid phone number.
Family Teacher of Record (ToR)
Special Accommodations: Please list any allergies/medical conditions.
I, a parent/guardian of an Excel Academy Charter School (“Charter School”) student, hereby acknowledge my intent to attend the above-described field trip as a parent/guardian participant. I acknowledge that I am required to supervise my student at all times during the field trip and to secure transportation for my student to and from the field trip.

As a parent/guardian participant, I acknowledge that I shall adhere to any applicable Charter School policies and procedures, and that I will follow all direction and guidance of the Charter School employee(s) who are responsible for the field trip.

As a parent/guardian participant, I acknowledge that I shall be responsible for any and all fees/costs associated with my participation in the field trip, unless otherwise notified in advance by the Charter School.

I understand that in determining that participation in this field trip has educational value, the Charter School has not investigated or approved its safety, the qualifications or financial responsibility of any person or firm involved in the field trip, or the facilities or equipment that may be used.

In addition, I acknowledge the Charter School shall not provide or approve transportation to or from this field trip. All participants are expected to secure their own transportation to and from the field trip destination.

I hereby waive, release and discharge the Charter School, its employees and agents, and the State of California from any and all claims for damages or personal injury, accident, illness, death, or property damage occurring during or by reason of the field trip. I acknowledge and understand that the field trip may involve an element of risk and/or danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.

I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS RELEASE OF LIABILITY IS A CONTRACT BETWEEN MYSELF AND THE CHARTER SCHOOL. My signature below acknowledges my participation in this field trip and voluntary agreement to the foregoing terms.

By signing my name below, I hereby acknowledge my intent to sign this Field Trip Parent/Guardian Participation and Release of Liability, and affirm all of the above.
Parent Signature*

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WAIVER FOR SIBLING (NON-STUDENT) ATTENDEE AT FIELD TRIP
Sibling/Non-Student Name

First NameLast Name
Sibling/Non-Student Age
Parent Name

First NameLast Name
Parent Email
example@example.com
Parent Phone
Please enter a valid phone number.
Family Teacher of Record (ToR)
Special Accommodations: Please list any Allergies/Medical Conditions
I, parent/guardian of a Excel Academy Charter School (“Charter School”) student, hereby acknowledge that my Charter School student’s sibling, identified above, will also attend the above-referenced field trip. I acknowledge that the sibling’s participation in this field trip is voluntary, and that I, as the parent/guardian, shall be fully responsible for the sibling during the course of the field trip and am required to supervise the sibling at all times during the field trip. I acknowledge that the above-referenced sibling shall not attend a Charter School field trip without my presence or the presence of another parent/guardian of the sibling.

I understand that in determining that participation in this field trip has educational value, the Charter School has not investigated or approved its safety, the qualifications or financial responsibility of any person or firm involved in the field trip, or the facilities or equipment that may be used.

I understand that the Charter School shall not provide or approve transportation to or from this field trip. All participants, including the sibling, are expected to secure their own transportation to and from the field trip destination.

I hereby waive, release and discharge the Charter School, its employees and agents, and the State of California from any and all claims for damages or personal injury, accident, illness, death, or property damage occurring during or by reason of the field trip to this sibling. I acknowledge and understand that the field trip may involve an element of risk and/or danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.

I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS RELEASE OF LIABILITY IS A CONTRACT BETWEEN MYSELF AND THE CHARTER SCHOOL My signature below authorizes my Charter School student’s sibling to participate in this field trip and my voluntary agreement to the terms of the agreement, waiver and release. By signing below I represent that I have the authority to sign this form on behalf of any minor(s) listed above
Parent Signature*

Clear
Should be Empty:

VOLUNTARY FIELD TRIP AUTHORIZATION AND RELEASE OF LIABILITY

Field Trip Authorization, Waiver, and Release of Liability

Emergency Medical Information and Consent

Field Trip Parent/Guardian Participation and Release of Liability

WAIVER FOR SIBLING (NON-STUDENT) ATTENDEE AT FIELD TRIP