PERMISSION AND INFORMATION FORM

TRIP INFORMATION

School: Tustin High School	Destination: Varies	Date of Trip: Various Saturdays and Sundays
Group: Key Club	Duration:	X Day	Overnight	Advisor: Lubin
Activity/Purpose: To volunteer	for various organizations	throughout the community
Departure: Date: Varies Time: Varies	Return: Date: Varies Time: Varies	Transportation: Self or carpool School Vehicle: Other:

STUDENT INFORMATION

Name:	Date of Birth:
Street Address:
City/Zip:	Phone: Home ( )	Parent Work: ( )
Parent/Guardian Name:
Insurance Company:	Policy #
Allergies/Medications/Medical Condition: If you have any special instructions, kindly attach an explanation and check the appropriate box.	Instructions Attached No Instructions Attached

EMERGENCY CONTACT (Use a contact other than parent/guardian listed above)

Name:	Relationship:
Street Address:
City/Zip:	Phone: Home ( )	Work: ( )

No student shall be prevented from making the field trip or excursion because of lack of sufficient funds.

STUDENT CONDUCT

The Principal/designee has thoroughly explained the purpose of this trip, safety rules, and rules of conduct. In addition to rules and consequences established by the transportation provider, facility, or other organizer of this event, all school and district rules apply, including those related to alcohol and drug use. The consequences for violating those rules will be the same as if the violation were committed at school.

TO THE PARENTS

Please read carefully the information about the trip, itinerary, and other information provided above. Complete the contact and emergency information. Be sure to check the appropriate box and attach special medical instructions as necessary. Please note that all school rules, including those related to alcohol and drug use will apply while on this field trip. Your student will be held accountable for behavior as if he or she were at school.

LIABILITY RELEASE

As provided for in California Education Code Section 35330, the parent/guardian waives all claims against the State of California or the Tustin Unified School District, its officers, employees and agents, for injury, accident, illness or death occurring during or by reason of this trip.

MEDICAL AUTHORIZATION

In the event of any illness or injury, the parent/guardian hereby consents to whatever x-ray, examination, anesthetic, medical, dental, or surgical diagnosis and/or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of the student. It is understood that the resulting expenses will be the responsibility of the parent/guardian and the school or district does not provide medical coverage for participants in this activity.

I have been informed about this field trip and agree to the Student Conduct, the Liability Release and Medical Authorization.

_________	___________________	_________

Parent/Guardian Signature	Date	Student Signature	Date