Encinitas Union School District
REQUEST FOR STUDENT VOLUNTARY PARTICIPATION
ONE-DAY OR SEASONAL ACTIVITY
Check one: Release to participate in - On-campus activity _____ Off-campus activity ____
____________________________________________________________wishes to participate in (Students Name)
___CYT Production of James and the Giant Peach, Pacific Beach Middle School _________
(Activity)
on Thursday, Nov. 10, 2016 from __8:30__ am to _1:30 __ pm
Transportation will be by ______Private car_____.
District vehicle, private car (separate form/insurance required), other, or not applicable (n/a)
It is necessary that the parents specifically request that their child be included in this activity. This activity is voluntary. The school will furnish supervision for this event, but parents should understand that supervision would end at the time stated above. The school will take every precaution to assure the welfare and safety of your son/daughter participating in this activity. However, it is important that you understand that the school cannot assume financial or legal liability in case of injury or accident. If you authorize your child to remain in the custody of another person after district provided supervision ends, specific written authorization must be given. No district supervision will be present once you authorize the release of your child to another person. The district cannot assume any responsibility for your Child’s welfare once direct district control and supervision ends.
If you wish your son/daughter to participate in the above-described activity, please complete the request for participation form below, and return it to the school immediately.
(Cut on dotted line and return lower portion)
C....................................................................................................
PARENT REQUEST FOR STUDENT PARTICIPATION
This completed form must be returned to the teacher before student can participate
In consideration of permission granted I/we hereby waive all claims which I/we might have against the Encinitas School District or the State of California, their officers, agents, and employees for injury, accident, illness, or death occurring during or by reason of the above described activity.
(California law (Education Code 35330) provides that any person making a field trip or excursion waives all claims against the school district and the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion.)
_________________________________ has permission to attend the
Name of Student CYT Production of James and the Giant Peach,
Pacific Beach Middle School
Scheduled for Thursday, Nov. 10, 2016 from __8:30__ am to _1:30 __ pm
In the event of an accident, or sudden illness, the school district has my permission to render whatever emergency medical treatment may be deemed necessary for the above named student.
_______________________________________________________________________________________
Date signed Signature(s) of Parent(s) or Guardian Daytime phone number
If transportation is by private vehicle: I would like to drive _______ and I have _______seat belts
I will ensure that every child under the age of 8 who is under 4’9” tall will be secured in a booster seat in the back seat. Any child under the age of 8 who is 4’9” or taller may be secured by a safety belt in the back seat.
PERMISSION TO RELINQUISH MY CHILD’S CUSTODY TO ANOTHER PERSON
I, _____________________________ as parent or guardian of ________________________,
Parent/guardian Student
authorize the Encinitas School District to relinquish custody and supervision of my child to the custody
and care of _____________________________. I understand that district provided supervision and
Authorized individual
the field trip will end when the above authorized individual assumes my child’s custody and control.
________________________ _________________________________
Date signed Signature(s) of Parent(s) or Guardian
DISTRICT USE ONLY
Teacher: ______________________________ Teacher Signature: ______________________________
Authorized Individual Name: ______________________________________________________________
Authorized Individual Signature: __________________________________________________________
Date: ________________________________________ Time: ___________________________________
.
REQUEST FOR STUDENT VOLUNTARY PARTICIPATION
ONE-DAY OR SEASONAL ACTIVITY
Check one: Release to participate in - On-campus activity _____ Off-campus activity ____
____________________________________________________________wishes to participate in (Students Name)
___CYT Production of James and the Giant Peach, Pacific Beach Middle School _________
(Activity)
on Thursday, Nov. 10, 2016 from __8:30__ am to _1:30 __ pm
Transportation will be by ______Private car_____.
District vehicle, private car (separate form/insurance required), other, or not applicable (n/a)
It is necessary that the parents specifically request that their child be included in this activity. This activity is voluntary. The school will furnish supervision for this event, but parents should understand that supervision would end at the time stated above. The school will take every precaution to assure the welfare and safety of your son/daughter participating in this activity. However, it is important that you understand that the school cannot assume financial or legal liability in case of injury or accident. If you authorize your child to remain in the custody of another person after district provided supervision ends, specific written authorization must be given. No district supervision will be present once you authorize the release of your child to another person. The district cannot assume any responsibility for your Child’s welfare once direct district control and supervision ends.
If you wish your son/daughter to participate in the above-described activity, please complete the request for participation form below, and return it to the school immediately.
(Cut on dotted line and return lower portion)
C....................................................................................................
PARENT REQUEST FOR STUDENT PARTICIPATION
This completed form must be returned to the teacher before student can participate
In consideration of permission granted I/we hereby waive all claims which I/we might have against the Encinitas School District or the State of California, their officers, agents, and employees for injury, accident, illness, or death occurring during or by reason of the above described activity.
(California law (Education Code 35330) provides that any person making a field trip or excursion waives all claims against the school district and the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion.)
_________________________________ has permission to attend the
Name of Student CYT Production of James and the Giant Peach,
Pacific Beach Middle School
Scheduled for Thursday, Nov. 10, 2016 from __8:30__ am to _1:30 __ pm
In the event of an accident, or sudden illness, the school district has my permission to render whatever emergency medical treatment may be deemed necessary for the above named student.
_______________________________________________________________________________________
Date signed Signature(s) of Parent(s) or Guardian Daytime phone number
If transportation is by private vehicle: I would like to drive _______ and I have _______seat belts
I will ensure that every child under the age of 8 who is under 4’9” tall will be secured in a booster seat in the back seat. Any child under the age of 8 who is 4’9” or taller may be secured by a safety belt in the back seat.
PERMISSION TO RELINQUISH MY CHILD’S CUSTODY TO ANOTHER PERSON
I, _____________________________ as parent or guardian of ________________________,
Parent/guardian Student
authorize the Encinitas School District to relinquish custody and supervision of my child to the custody
and care of _____________________________. I understand that district provided supervision and
Authorized individual
the field trip will end when the above authorized individual assumes my child’s custody and control.
________________________ _________________________________
Date signed Signature(s) of Parent(s) or Guardian
DISTRICT USE ONLY
Teacher: ______________________________ Teacher Signature: ______________________________
Authorized Individual Name: ______________________________________________________________
Authorized Individual Signature: __________________________________________________________
Date: ________________________________________ Time: ___________________________________
.