Fullerton Joint Union High School District – TROY HIGH SCHOOL
Field Trip Participation Card
Please sign top &
bottom and turn
in on March 31
Student’s Name __________________________ID# _______ Grade 12 Birthdate __________
(last)
(first)
Parent’s Name ____________________ Phone (home) _____________ work ______________
Address ______________________________________________________________________
(number)
(city)
(zip)
EVENT:
Off Campus Troy Tech Internship
DATE:
2015-2016 Academic School Year and Summer 2015 as scheduled
TRANSPORTATION: Arranged by Student’s Family
Parent permission to participate: __________________________________________________
(PARENT SIGNATURE)
If parent’s unavailable, please contact: _____________________________________________
(last)
(first)
_____________________________________________________________________________
(cell number)
(home number)
(relationship)
Medical Alert Information: (allergies, etc) ___________________________________________
_____________________________________________________________________________
AUTHORIZATION FOR TREATMENT OF MINOR
I/We, the undersigned, parent(s) of __________________________, a minor, do hereby authorize any
hospital or medical center as agent(s) of the undersigned to provide any x-ray examination, anesthetic,
medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is
rendered under the general supervision of any physician and surgeon licensed to practice in the State of
California, whether such diagnosis or treatment is rendered at the official 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 and is given to provide authority and power on the part of our aforesaid
agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the
aforementioned physician, in the exercise of his best judgment, may deem advisable. The authorization
is given pursuant to the provisions of Section 25.8 of the California Civil Code. This authorization shall
remain in effect until May 26, 2016, unless sooner revoked in writing and delivered to said agent(s).
I/We hereby authorize any hospital which has provided treatment to the above-named minor pursuant
to the provisions of Section 25.8 of the California Civil Code to surrender physical custody of such minor
at my/our above-named agent(s) upon the completion of treatment. This authorization is given
pursuant to Section 1283 of the California Health and Safety Code.
Medical Insurance Co.__________________________________ Policy/Group#___________________
Signature of parent/legal guardian____________________________________ Date ______________