Excel Academy Permissions Slip and Authorization Form

VOLUNTARY FIELD TRIP AUTHORIZATION AND RELEASE OF LIABILITY - STUDENT
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 1 Phone Number*
Please enter a valid phone number.
Parent 1 Email*
example@example.com
Parent 2 Name

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

Clear
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
Should be Empty:

VOLUNTARY FIELD TRIP AUTHORIZATION AND RELEASE OF LIABILITY - STUDENT

Field Trip Authorization, Waiver, and Release of Liability

Emergency Medical Information and Consent