Official LAUSD Field Trip Permission Slip

Download or print the official form below

LAUSD Field Trip Permission Slip and Authorization for Medical Care

Fillable Digital Version

Use the form below for a digital version you can fill out and print

To the Principal of James Monroe High School:

has my permission to participate in the

(Student Name: please print)

field trip location:
on
Departure time:A.M./P.M.

Date(s)

Return time:A.M./P.M.
Supervising Teacher (please print):

LUNCH

Student will be at school during lunch.
Student will be off-site during lunch

PARENT MUST CHECK OPTION BELOW:

My child is requesting a lunch from the Cafeteria, I will send appropriate payment based on my child's meal eligibility (free, reduced, full price)
My child will bring a sack lunch without liquid.

METHOD OF TRANSPORTATION

Student will ride on School Bus
Student will ride in Private Vehicle.
Student is Walking.
Other
Date:

Parent or Guardian Authorization Signature

(INFORMATION TO BE COMPLETED BY PARENT AND TO BE REMOVED BY SUPERVISING TEACHER)

AUTHORIZATION FOR MEDICAL CARE

I permit the School District to transport/house/care for my child as necessary if an (non-medical) emergency occurs during the field trip. Should it be necessary for my child to have medical care while participating in this trip, I hereby give the School District personnel permission to use their judgment in obtaining medical care for the child, and I give permission to the health care provider selected by the School District personnel to render medical care deemed necessary and appropriate by the provider. I understand that the District is responsible for the conduct or safety of a student only while the student remains under the constant, direct and immediate supervision of the field trip supervisor(s). I also understand that for field trips where constant, direct and immediate supervision isn't possible, the District requires students to be insured under separate, "Short Term 24-Hour" coverage.

Student Name:
Home Address:
Home Telephone Number:
Business Telephone Number:
Emergency Telephone Number:

Authorized Signature of Parent or Guardian

Parent or Guardian's Name (please print):
Date:
PLEASE CHECK HERE IF INSTRUCTIONS FOR SPECIAL MEDICAL TREATMENT FOR THE STUDENT ARE ON FILE IN THE SCHOOL.

PARENTS, PLEASE NOTE: Section 35330 of the California Education Code states in part: "All persons making the field trip shall be deemed to have waived all claims against the District or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion". Accident insurance can be purchased for a minimum daily rate by contacting the school.

To be completed only upon emergency release of student to authorized parent or guardian during the trip. Student released to:

Parent or Guardian name (please print)

Signature

REF-2111.1

Division of Instruction

Page 54

December 14, 2015