Field_Trip_Waiver 0218 Final.pdfIf yes, please provide a medical clearance to attend and participate in this event. 
Last Revised February, 2018 

 
PERALTA COMMUNITY COLLEGE DISTRICT 
FIELD TRIP/EXCURSION WAIVER AND MEDICAL AUTHORIZATION FORM 

(Description of Activity) 
                           
(Course Name and #)   		(Department)     			(Instructor) 

(Destination)    		(Start Date/Time)   				(Return Date/Time) 
 
“All persons making the field trip or excursion shall be deemed to have waived all claims against the Peralta Community College District or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion. All adults taking out-of-state field trips or excursions and all parents or guardians of students taking out-of-state field trips or excursions shall sign a statement waiving such claims.” 
(California Code of Regulations, Title 5, Section 55450) 
 
In the event of illness or injury, I do hereby consent to whatever x-ray, examinations, anesthetic, medical, surgical, emergency medical transportation, hospital care or dental diagnosis or treatment from a licensed physician, surgeon, or dentist as deemed necessary for my safety and welfare. I understand that the resulting expenses will be my responsibility. 
 
I agree to abide all rules and regulations governing my conduct during the trip. Any violation of these rules and regulations may result in my being sent home at my expense. 
 
By signing my (our) name, I (we) hereby certify that I (we) have read and fully understand the above notice and do hereby give my (our) consent for the student to participate in the field trip/excursion. 

(Print Name)     		(Signature)     					    (Date) 

(If less than 18 years, name and signature of parent/guardian) 

(Address)          									(Phone No.) 

(Medical Insurance Carrier)   	        (Policy No.)   				(Subscriber ID No.) 
 
In the event of an illness or accident, please notify: 
              
(Name)     					(Address)    				(Phone No.) 
 
Do you have any conditions that may limit your ability to fully participate in all field trip activities? 
   No      Yes 
Circle One

Authorized or approved by ___________________________________________________________________________________________________     
			(AP, VP or Dean -Print Name)                  (Signature)             (Date)

(Instructor: please maintain a copy of this waiver for one year from the date of the event) 
 (Instructor: please maintain a copy of this waiver for one year from the date of the event)