Excel Academy Permissions Slip and Authorization Form

Name of Field Trip*

Date of Field Trip*

Date

Sibling/Non-Student Name*

First NameLast Name

Sibling/Non-Student Age*

Parent Name*

First NameLast Name

Parent Email*

example@example.com

Parent Phone*

Please enter a valid phone number.

Family Teacher of Record (ToR)

Special Accommodations: Please list any Allergies/Medical Conditions

I, parent/guardian of a Excel Academy Charter School (“Charter School”) student, hereby acknowledge that my Charter School student’s sibling, identified above, will also attend the above-referenced field trip. I acknowledge that the sibling’s participation in this field trip is voluntary, and that I, as the parent/guardian, shall be fully responsible for the sibling during the course of the field trip and am required to supervise the sibling at all times during the field trip. I acknowledge that the above-referenced sibling shall not attend a Charter School field trip without my presence or the presence of another parent/guardian of the sibling.

I understand that in determining that participation in this field trip has educational value, the Charter School has not investigated or approved its safety, the qualifications or financial responsibility of any person or firm involved in the field trip, or the facilities or equipment that may be used.

I understand that the Charter School shall not provide or approve transportation to or from this field trip. All participants, including the sibling, are expected to secure their own transportation to and from the field trip destination.

I hereby waive, release and discharge the Charter School, its employees and agents, and the State of California from any and all claims for damages or personal injury, accident, illness, death, or property damage occurring during or by reason of the field trip to this sibling. I acknowledge and understand that the field trip may involve an element of risk and/or danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.

I HAVE CAREFULLY READ THIS AGREEMENT, WAIVER, AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS RELEASE OF LIABILITY IS A CONTRACT BETWEEN MYSELF AND THE CHARTER SCHOOL My signature below authorizes my Charter School student’s sibling to participate in this field trip and my voluntary agreement to the terms of the agreement, waiver and release. By signing below I represent that I have the authority to sign this form on behalf of any minor(s) listed above

Parent Signature*

WAIVER FOR SIBLING (NON-STUDENT) ATTENDEE AT FIELD TRIP