Permission to Participate in School-Sponsored Activities

SRVUSD STUDENT ACTIVITY/TRIP PERMISSION/EMERGENCY FORM
Iron Horse Middle School

Student Name:

Grade:

Parent / Guardian:

Home Phone Number:

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Work Phone Number:

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Cell Phone Number

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I give consent and permission for the student named above to attend any and all activities for which they are eligible. This permission slip shall serve for any and all Iron Horse Middle School activities and events not limited to dances, field days/carnivals.

TRANSPORTATION: Charter Bus OR Private Vehicle (volunteer drivers). If by private car, I understand that seat belts and/or seats are required by law to be worn/used by all passengers. I further understand that safety considerations and California State Law require that no child ride in the front passenger seat of my vehicle. I also understand that children MUST be secured in an appropriate passenger restraint system (safety seat or booster seat) until they reach six (6) years of age or weigh sixty (60) pounds.

INFORMATION: Education Code Section 35330 authorizes the governing board of any school district to conduct field trips or excursions for students in connection with courses of instruction of school related social, educational, cultural, athletic or school band activities to and from places in the state, any other state, the District of Columbia, or a foreign country. Field trips or excursions may be connected with such courses of instruction or such school activities that further the student's education and participation is voluntary. As a voluntary event, no special attendance credit is given for participation, and an alternative activity at school will be provided if my child does not participate.

PARENT/GUARDIAN TO COMPLETE EMERGENCY INFORMATION:
Please check the appropriate statement regarding student's health.

My child has no known health problems.

My child has the following known health problems:

(Please also identify any medication that the child may need during the course of this trip or event.)

PLEASE CHECK #1 or #2 BELOW TO INDICATE DESIRED ACTION IN THE EVENT OF ACCIDENT OR EMERGENCY.

1. In the event of an accident or emergency, when a parent/guardian is unavailable, I hereby authorize a representative of the school to make such arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such care and treatment ofmy child as he/she considers necessary. In the event said physician is not available at any time I authorize such care and treatment to be performed by any licensed physician or surgeon. THE UNDERSIGNED PARENT/GUARDIAN FULLY UNDERSTANDS HE/SHE IS RESPONSIBLE TO PAY ALL COSTS INCURRED AS A RESULT OF THE FOREGOING.

Physician's Name:

Physician's Phone Number

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Medical Insurance Name (Kaiser, etc.):

Medical #:

2. I do not choose the above statement and desire the following action be taken:

Action:

WAIVER: California law provides as follows: "All persons making the field trip or excursion shall be deemed to have waived all claims against the district or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion" (Education Code Section 35330). I acknowledge that as a condition of my child's participation, I agree this waiver of all claims shall be extended to any and all claims against the school, its employees and volunteers, the district, its governing board, the individual members there, and all other district officers, agents and employees. Further, I agree to indemnify and hold harmless the school, its employees and volunteers, the district, its governing board, the individual members thereof, and all other district officers, agents and employees for any injury, harm, accident, illness, death, loss, liability, cost, expense or claim of any type whatsoever (including attorney's fees) or damage to personal property occurring during or by reason of this excursion/field trip event.

I understand that participation in this field trip involves a certain degree of risk. I have carefully considered the risk involved and consent for my child to participate in the field trip.

My signature below authorizes my child to participate in the activities listed above:

Use the space above to sign your name

Date:

SRVUSD STUDENT ACTIVITY/TRIP CODE OF CONDUCT AGREEMENT
Iron Horse Middle School

Student Name:

Grade:

Dances and other school functions are viewed as an opportunity for students to socialize in a supervised and safe environment. Student's behavior and attire should reflect the rules and regulations of Iron Horse Middle School. Attendance at after school functions is a privilege that all Iron Horse students must earn. The following are Student Code of Conduct requirements and expectations expected of all students at these events:

Respecting public and private property.

Obeying all policies of the SRVUSD, school and organization in effect for the duration of the activity.

Conducting oneself in a courteous and respectful manner at all times.

Following directions and instructions of chaperones without fail.

All students must dress appropriately. Any violation of the dress code will result in the student not being permitted to enter or remain at the event.

Administrators or chaperones reserve the right to confiscate and hold onto any cell phone for the duration of the event should it be deemed that it was being used in an inappropriate manner.

All activities are open to IHMS students ONLY. No guests, former students or siblings are allowed. Students must be in good disciplinary standing to be eligible for some events.

If the event requires tickets, students must have a current ID card to purchase one during the purchasing window at school (no tickets will be sold at the door). The same ID card must be shown to enter the event. There are refunds once a ticket for a dance or school activity is purchased. There are no "in and out" privileges at events. Once a student exits an event, he/she will not be readmitted. For all school events, students and guests must behave in a safe and appropriate manner.

Students must remain at events for the entire duration unless signed out by a parent or guardian (no re-entry) through an administrator.

After the event, students will be sent outside the MPR to "find" their ride home and must be picked up immediately.

I understand the behavior expectations and the consequences of violating the Student Code of Conduct. T have read this code and agree to comply with all of the rules and regulations as outlined by the staff supervisor.

Student name:

Use the space above to sign your name

Date:

I understand and support the behavior expectations and the consequences ifmy child violates the Student Code of Conduct. My child has read this code and will comply with all of the rules and regulations as outlined by the staff supervisor.

Parent / Guardian Name:

Use the space above to sign your name

Date: