Sierra Unified School DistrictFOOTHILL MIDDLE SCHOOL

PARENT CONSENT FOR VOLUNTARY FIELD TRIP AND EMERGENCY MEDICAL AUTHORIZATIONThis 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) Transporation: Walk_____Van_____Bus__X__Private_____ *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 ResponsibilityI 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 ArrangementsI, ____________________________________, 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

________________________________ EMERGENCY MEDICAL AUTHORIZATION(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 theirjudgment in obtaining emergency medical services for my ___________________________________child. I further authorize any individual selected by Address

Foothill Middle School personnel to render such emergencymedical 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 hospitalcosts 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 madeavailable 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 _____from account _____from cash

_____My child will purchase mile only _____ _____from account _____from cash

_____My child will bring a sack lunch from home

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

__________________________________________________________________________________________________