BRITTAN SCHOOL DISTRICT

2340 Pepper Street

Sutter, CA 95982

530-822-5155

Parental Permission for School Related Field Trips and Activities

I hereby agree that my child has my permission to participate in the following activity:

Activity:  
Location:  
Date:  

 

Transportation  will be provided by:

 This vehicle will be driven by:   

 

District Bus 

 

Licensed School Bus Driver

 

Private Car  

 

District Employee

 

Walking 

 

Parent

 

Commercial

 

 

 

Time of Departure:

 

Time of Return:

 

This activity for the students will be under the supervision of:


I further agree that in case of medical emergency, illness or injury, the supervisor has my express permission to take the above-named student to a doctor or medical facility to receive emergency treatment pursuant to the following authorization:

I, the undersigned parent/guardian of                                                                                         a minor, do hereby authorize the faculty members of the Brittan School District supervising the activity herein described, as my agent to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable.

 This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California

IMPORTANT MEDICAL INFORMATION THE SUPERVISOR SHOULD KNOW:

 

Emergency Numbers:

Name of Family Doctor 

 

Doctor's Phone    

 

 

Signature of Parent/Guardian

 

Home Phone Number

 

Date: