PARENT PERMISSION FORM
To the principal of Our Lady of Guadalupe School
I hereby request that _____________________________________________ participate
in the field trip to ________________________________________________________
Time and Date __________________________________________________________
I agree to direct my child to cooperate and conform to directions and instructions of the supervisory personnel in charge of the field trip.
_____�� I certify that my child is at least six (6) years old and at least sixty (60) lbs. I understand that the law requires seatbelts for each person in the car who is age six (6) and weighs over sixty (60) lbs.
_____� �I
certify that my child is not six (6) years old or at least sixty (60) lbs.
Therefore, I understand that I must provide a safety seat or a booster seat to
be used for his/her transportation as required under
�http://www.chp.ca.gov/html/boosterseats.html
I understand that any expenses incurred for medical treatment of my child will be first submitted to my personal medical/dental insurance plans. Unpaid benefits can be submitted to Myers-Stevens as a secondary provider.
CONSENT FOR TREATMENT
(I), the undersigned parent or legal guardian of __________________________________________, a minor, do hereby authorize a representative Our Lady of Guadalupe School as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care that is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the California Medicine Practice Act, on the medical staff of an accredited 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 the above-mentioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care that the above mentioned physician in the exercise of his or her best judgment may be deemed advisable.
Parent/Guardian Signature ______________________________________________ Date ____/____/____
YES ______ NO______ I offer to Drive _____________________________________________________
������������������������������������������������������������������������������� ��������������� (If yes, please fill out bottom portion of this form)
CERTIFICATION AND AUTHORIZATION
I have offered to use my privately owned vehicle for transporting students to a school related activity. I certify that I possess a valid, unrestricted California Driver�s License and that I currently have $100,000/$300,000 in automobile liability insurance coverage on the automobile to be used and that the most up to date copy of the declaration page of my insurance is on file in the office for the current school year.
Name of Driver ____________________________________ ��Driver�s License # ____________________
Address of Driver __________________________________ ��Phone ______________________________
�__________________________________
Make of Vehicle ___________________________________ ��Yr./Model/Style ______________________
Auto License _____________________________________ ���No. of Passenger Seat Belts _____________
Signature _________________________________________
Persons who offer to use their privately owned vehicles for student transportation to school related activities should be aware that although there is a liability insurance policy for the diocese, it is the individual driver�s own insurance that must provide the coverage for him/her in case of an accident.