ࡱ> GXFm bjbj˖˖ "bbh +PP0008h0A### A A A A A A A$rC(F/A#!0###/ADDA&&&#R8 A&# A&&= @)'f#j?:@ZA0A@F# Ft@F@@##&#####/A/A$$###A####F#########PB :   MENDOCINO-LAKE COMMUNITY COLLEGE DISTRICT FIELD TRIP/EXCURSION NOTICE AND MEDICAL AUTHORIZATION--MINOR  has my permission to participate in the following voluntary activity and, as such, is not required by the district: Departure Date & Time: Return Date & Time: Pursuant to the California Code of Regulations, Subchapter 5, Section 55450, I understand that I hold Mendocino-Lake Community College District, its officers, agents and employees harmless from any and all liability or claims, which may arise out of or in connection with my childs participation in this activity. In the event of illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.  Medical Insurance Carrier Policy No. Address A special note to Parent/Guardian: (1) All medications must be registered on this form; (2) All drugs, excepting those which must be kept on the students person for emergency use, must be kept and distributed by the staff; (3) [ ____ ] Check here if there are no special problems that the staff should be aware of and no medication is required on the trip; (4) If any medication is to be taken by student, list them here: (Name of drug and reason)  If your son or daughter has a special medical condition, kindly attach a description of the problem to this sheet. I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violation of these rules and regulations may result in that individual being sent home at the expense of his/her parent/guardian. I understand and acknowledge that unless specifically advised otherwise, the college is not providing the transportation and it is my responsibility to arrange for my transportation to and from the activity. If the college is providing transportation but I do not use the transportation, I am responsible to make my own arrangements and the college assumes no responsibility or liability of any kind. If the college is not providing transportation I further understand: The driver of the vehicle in which the student is riding, either as driver or passenger, is not driving on behalf of or as an agent of the college, and the college has not verified the driving record of the driver, the liability insurance of the vehicle, or the condition of the vehicle; The college is in no way responsible, nor does the college assume liability, for any injury or loss which may result from the students transportation; Although the college may assist in coordinating the transportation and/or recommend travel times, routes, car pooling, or caravanning, recommendation(s) or travel assistance provided is not mandatory.  Parent Name (Print) Phone  Parent Signature Date  Student Signature Date     Field Trip/Excursions--Minor STUDENT ID   9UXYvwy     W ¾zpzjVBz&jh3CJOJQJUmHnHu&jhqq%CJOJQJUmHnHu h3CJhsCJOJQJh3CJOJQJ"jh3OJQJUmHnHuh35CJOJQJh3CJOJQJ h3CJh`h3CJOJQJh3h hqq%hqq% hshshsjhqq%UmHnHuhh35CJOJQJh35CJOJQJ  9Uvw  W X $ % ' Y Z !# ! !$a$ gdqq%gds $^a$gdW X $ % & ' Y Z ! @ D F d f !"#$%jkùßÕËËÀçßßvlX&jh3@OJQJUmHnHuh3CJOJQJh3CJOJQJh3>*CJOJQJhsCJOJQJhM0CJOJQJh3OJQJ"jh2OJQJUmHnHuh3CJOJQJh3CJOJQJh`@OJQJh`@CJOJQJaJ h`h`@CJOJQJaJh3@OJQJ!$%jk#<=?hjkmngdsm$ $a$gdsm$  !gdsm$$ & Fa$ !$a$ !=>ghiklnoqrt䪢hsh3h&.jh&.UhsCJOJQJ"jh3OJQJUmHnHu&jh3@OJQJUmHnHuh3CJOJQJh3CJOJQJ!h3@CJOJQJmHnHunpqst$a$$a$gds$&d P a$gds$a$ 00&P+p  ,p  -p  .p  1/R 4 5 6 7 :pqq%/ =!"#$% s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH NN  Heading 1$@&6@ B*CJEH OJQJFF  Heading 2$$@&a$ CJOJQJFF  Heading 3$$@&a$ CJ0OJQJHH  Heading 4$ & F@& CJOJQJNN  Heading 5$ & F@&5CJOJQJ\JJ  Heading 6$$ `@&a$5CJFF  Heading 7$$@&a$ CJOJQJJ@J  Heading 8$$@&a$5CJOJQJ@ @@  Heading 9 $$@&a$5\DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List NKN Salutationd@CJOJQJDBD Body Textd@CJOJQJL@"L Signature$dp@CJOJQJFF Signature Job TitleBLBB Datedh0$@CJOJQJLQRL Inside Address Name $a$TRT Inside Address$da$@CJOJQJF@bF Header$ !a$ @OJQJ4 @r4 Footer  !<>< Title$a$5CJOJQJDPD Body Text 2$a$ CJOJQJVCV Body Text Indent$h^ha$ CJOJQJDQD Body Text 3$a$ CJOJQJ^R^ Body Text Indent 2 $ 6^`6a$HH qq% Balloon TextCJOJQJ^JaJN/N qq%Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< &  " ***-W  n @  '@H 0(   &@(  VB   C D"?VB   C D"?VB  C D"?VB  C D"?VB  C D"?VB  C D"?VB  C D"?VB  C D"? 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