Get everything signed by Monday May 10th and turn it in to Ms. Santa Cruz in room C-104.

1. Birthday of Child (MIODDATR) Age of Child
Waiver Kept on File Until (Three yearsafter 18th Birthda$
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
A World We Can Change
A. Clean Air Conference& Expo for l{igh SchoolStudents
M:ry 27,2010
PARENTAL CONSENT AIYD WAIVER FORM
Dear Parentor Guardian:
This consent and waiver fonn must be signed before your child can participate in the South
CoastAir Qualify Management District high schoolcleanair conference describedbelow. If you
do not sign, your child will not be allowed to participate. Thank you for your cooperation.
Sincerely,
The SouthCoastAir Quality Management
District
[, the urrdersignedparent/guardianof a minor, do
hereby authoize my child to participatein The SouthCoastAir Quality Management District's
A World 'We Can Change - A Clean Air Conference & Expo for Iligh School Students
('Conference") on Thursday, i&,{ay27,2010 at the Los Angeles Convention Center. The
Conferencewill offer information on greenjob training, environmentalvolunteer opporhrnities,
state-of-science technology displays, and the chance to network with leaders who are
transforming greater Los Angeles region toward low-emission vehicle techuologies,renewable
energy and cleanerair. The South CoastAir Quality ManagementDistict ("Dstrict') is the air
pollution conhol agency for all of Orange County, and for the urban portions of Los Angeles,
Riverside,and SanBernardinocounties.
Media Consent: I hereby authorizethe District to use photographsand/or videos of my child in
relation to the Conference. I consentto the useof my child's likenessin any and all publications,
outreach,or exhibits. I releasethe District ftom any and all claims for damages libef, slander,
of
invasion of privacy, or any other claim basedon the use of the above-mentioned materials. I
understand that thesematerials may be kept on file and/orusedby the District for potential future
usesand agreeto releasethe District from any and all liability arising from or in connectionwith
the taking,use,publicationor dissemination suchmaterials.
of
Assumption of Risks: Participation in the Conferencecarries with it certain inherent risks that
cannot be eliminated regardlessof the care taken to avoid injuries. The risks range from (1)
minor injuries,suchas scratches bmises,to (2) major i4iuries suchas concussions, (3)
and and
Parentor Guardian: pleaseinitial hereto acknowledge havereadthis page:
you
Parental
Cortsent Waiver Form - PageI of 2
&

2. catastrophicinjuries including death. I hereby assert that my child's participation in the
Conference is voluntary and that I knowingly assumeall such risks for any loss that n--.
including, but not limited i.--'.
occur as a result of my child's participationin this Conference,
rnjury to my child, injury to other participants, and damage to equipment and/or any other
property.
Waiver of Liability: I, for myself, my heirs, personalrepresentatives assigns,do hereby
or
release,waive, discharge, and covenant not to sue The SouthCoastAir Quality Management
District, its officers,employees, agents
and from liability from any and all claims including the
negligenceof The South Coast Atr Quality Management District, its officers, employees
and agents,resulting in personalinjury, accidents illnesses(including death),and property
or
loss arisingfrom, but not limited to, my child's participationin the Conference.
Indemnification and Ilold Harmless: I also agreeto INDEMNIFY AND HOLD The South
Coast Air Quality ManagementDistrict I{ARMLESS from any and all claims, actions,suits,
procedures,costs,expenses, damages liabilities, including attomey'sfeesbroughtas a result
and
of my child's participation in the Conferenceand to reimbursethem for any such expenses
incurred.
Severability: The undersigned further expressly agrees that the foregoing rvaiuer and
assumptionof risks agreementis intendedto be asbroad and inclusive as is perminedby the larr
of the State of California and that if any portion thereof is held invalid, it is agreedthat the
balanceshall,notwithstanding, continuein full'legal force andeffect.
Acknowledgment of Understanding: I have read this assumption risk, rvaiver of liability,
of
and indemnity agreement, fully understandthe terms, and understand that I am giving up
substantial rights, including my right to sue. I acknowledge that I am signing the agreement
freely and voluntarily, and intend by my signature to be a complete and unconditional
extentallowedby law.
releaseof all liability to the greatest
NAME OF PARENT OR GUARDIAN (PLEASEPRINT)
SIGNATURE PARENTOR GUARDIAN
OF DATE
Consent& Waiver Form - Page? of 2
Parental

3. DowneyUnifiedSchool District
ParentPermission Form - Secondary Schoots
Field TriplExcursion and Medical Authorization - *{i*or
lv"
has my perrrossion participate h rhe activiry/ies listed below
to
I fi.rllyunderstand followine;
the
l. Participation theseactivitiesis voluntary.
in
2- I may revoke this authorization any time by notifyingDUSDin writing.
ar
3. Revocation not effectiveuntil receiptis acknowledged DUSD.
is by
4. My child mustabideby all District andschoolruleswhile participaring this activiry.
in
As statedin CaliforniaEducation CodeSection 35330:
"All persons makingthefield trip or excursion
shallbe deemed havewaived claimsagainst District or the State Califomiafor any injury,
to all the of
illness,or deathoccurring
during or by reason ofthe field trip or excursion.*'
ReturnDate/Time
5 COn*t Ccnk(
Y )-l )2arr: a7 2'7 ,2olo
Kr?o" 3o a.nn
Consent Transport
to
In accordance Education 35350, signature permission transpu:tt applicable).
with Code my gives to (if
fidchoot Bus I School
EmployeeVPersonal
vehicle fi volunt..rs/
Personalvehicle other:
Consent to Treat
In the eventof illnessor injury, I do herebyconsentto whateverX-ray examination,anesthetic,
medical, surgicalor dentaldiagnosis treaimentand
or
hospitalcareareconsidered-necessary bestjudgment
in ihe ofthe attending
phpicians or dentistandpeiformedby or underth-e supervisionofa
memberof the medicalstaffof the hospital or facility fumishing medicalor dentalservices.
A specialnoteto parenrs/guardians accordancewith
in Educationcode 549423:
Checkhereifthere areno special problems the staffshouldbe awareofand no medications required thetrip.
that are on
f}
f-f
.t Checkhere your child hasmedication
if administered school.
at
' All medicationsmustbe attached this form with a physician'swriften instructionson dispensing.
on
r All prescriptions,
exceptingthosethat must be kept on the student'spersonfor ernergencyuse,1noSt krpt anddistributedby the
b"
staff.
n checkhereifno bloodtransfusions bloodproducts to be given.
or are Initial:
If your son or daughterhas a specialmedicalproblem, pleaseattach a descriptlonof that problem to this sheet.
The undersigned agrees defend,
to indemnifyandhold harmless DowneyUnifredSchoolDistricts,its Boardof Trustees,
the oflicers,agentgand
employees, individually andcollectively, from andagainstall costs,losses,
Ur uvru qrts 44$r!t 4rr wrrDr ru!Ds!' claims,demands,
Glailr|.t, uErltunqs, suits, actions,payments
sults, aCIlOnS, paymen$ andjudgments,in"tuOing
anqJUOgmentS, Inclucllng
legal and attomeyfees,arising from personalor bodily injuries, wrongful death,propertydamage othenvise,ho**no *urid, broughtor
or
recovered asainstany of the abovethat may arisefor any reasona,rising of or in ionnection *itt, mv child's participationin this activity.
sut
My signaturebelow alsosignifies that I havecounseled child on properconductandwill takefull responsibiliryfor anyimproperconducton
my
his/herpart.
Signature ofParent or Legal Guardian Date
Address where parent will be duringfield trip Phone where parent can be reached duringfield trip
HealthInsurance
Company/
MEDI-CAL PolicyNumber
DUSD - Instructional
Services
#33360 Rev.6/05