ALL GRAY AREAS MUST BE FILLED IN st

1 Period Teacher

PRINT Student Name

PARENTAL & MEDICAL AUTHORIZATION FOR MINOR/STUDENT PARTICIPATION IN DISTRICT-APPROVED FIELD TRIP Print Name has my permission to participate in the Dave & Buster's FUNraiser event on Friday, January 29th, 2016 between 7:15 a.m. and 12:00 pm. Students will be transported by bus from Lexington JH to Dave & Buster's and back to campus. Students will be chaperoned by teachers, administrators and parents. Dave & Buster's: 20 City Blvd W #1, Orange, CA 92868 (714) 769-1515 As stated in California Education Code Section 35330: I hereby agree for my child, myself, my heirs, administrators, executors and assigns, that I shall indemnify and hold harmless the Anaheim Union High School District, and the Lexington Foundation from any and all claims, demands, actions, or suits arising out of, or in connection with, my child’s participation in the above mentioned activities. I fully understand that participants are to abide by all rules and regulations governing conduct during the event. Any violation of these rules and regulations may result in school discipline. In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

My student has permission to walk home from the Lexington Campus at the conclusion of the event Initial in the box to approve

Medications (YOU MUST CHECK ONE)

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My child takes no medications. My child will be taking prescription or over-the-counter medications while participating in this activity. Appendix 7003.11B (Parent Request for the Administration of Medication Prescription and NonPrescription) has been completed and is on file in the Health Office. A description of any medical problem is attached.

In the event I am not available in an emergency, please notify: Name

Relationship

Phone #

Alt. Phone #

Medical Information: My child’s doctor is:

Dr.’s Phone #

Medical Insurance Carrier

Policy #

Parent/Guardian Signature

Date

Printed Name

Phone # Parent / Guardian Initial Here

Student Signature Revised 10/07/15 krm

Birth Date Appendix 7903.11A