Student Name 1905 Armacost AveLos Angeles, CA 90025Phone: 310.943.5444Fax: 310.231.3399

NEW WEST CHARTER SCHOOLOVERNIGHT OR EXPERIENTIAL FIELD TRIP PERMISSION FORM

ACKNOWLEDGEMENT AND ASSUMPTION OF RISK AND WAIVER OF CLAIMS

Please read this document carefully before signing. It contains important information and advises of certain risks. Participant and family are asked to acknowledge and assume risks and waive claims they might have in the event of injury or other loss. This document must be signed by the Participant (student) and by at least one parent or legally appointed guardian.

Education Code Section 35330 authorizes the governing board of any school district or charter school to conduct field trips or excursions for students in connection with course instruction or school related social, educational, cultural, athletic or school band activities to and from places in the state, out of state, the District of Columbia or a foreign country. Field trips or excursions, which may include overnight travel, may be connected with such courses and instruction or such school activities that further the student’s education.

Name of Field Trip: Washington and New York Trip

Location(s) of Field Trip: Washington DC and New York City (Manhattan)

Departure Date, Time and Location: Depart the morning of June 11th, 2018 from LAX airport-exact time From TBD

Return Date, Time and Location: Return the evening of June 15th, 2018 at LAX airport- exact arrival time from TBD

List Trip Activities: DC- Touring historical monuments and memorials such as the Lincoln and Jefferson

Memorials, the Vietnam War Memorial, the Air and Space Museum, the National Capital, etc. NY- Touring

locations such as the World Trade Center, Statue of Liberty, Battery Park, Central Park, Broadway play, etc.

No. of students expected to participate:

Names of supervising teacher(s), program staff, chaperone(s): Pete Sigler, John Arias, Jee Kim, and Britney

McBride).

Modes of Transportation (expected itinerary subject to change):Day 1- Flight from Los Angeles International Airport to Dulles Airport, chartered bus transport from Dulles Airport to chartered bus to National Mall for walk to Lincoln, Vietnam, Korea and WWII Memorials, and then chartered bus to the Capital Skyline Hotel.

Day 2- Walk from hotel to US Capitol, walk to Smithsonian (American History or Natural History), walk to Washington Monument and White House, (possibly take chartered bus to Georgetown University and from GU to Capital Skyline Hotel), walk to Capital Skyline Hotel.

Day 3- Take chartered bus from hotel to Arlington National Cemetery, chartered bus to Newseum, chartered bus to Jefferson, FDR and MLK Memorials, chartered bus to Smithsonian Air and Space Museum, take chartered bus to New York City ‘s Watson Hotel Manhattan.

Day 4- Take chartered bus from Watson Hotel Manhattan to Battery Park for views of Statue of Liberty and Ellis Island, walk to Wall Street and World Trade Center site, take chartered bus to Central Park, participate in bicycle tour of Central Park, chartered bus to hotel, walk to Broadway theatre, walk to Times Square, walk to hotel.

Day 5- Take chartered bus to Rockefeller Center, walk around Rockefeller Center area, chartered bus to Newark Airport, flight from Newark Airport to LAX.

What the Participant should bring for the trip: packing list to be distributed later

Acknowledgements and Agreements of Participant and Parent

I, Participant and Parent/Guardian (hereinafter “parent”) of minor Participant, for myself and on behalf of a minor Participant for whom I sign acknowledge and agree as follows:

1. Participation is Voluntary. I acknowledge that this field trip is voluntary and attendance by the Participant is not required and that an alternative educational activity will be provided if the parent/guardian does not give permission for him/her to participate.

2. Waiver of Claims Against New West Charter School. I understand that Education Code Section 35330 provides that all persons making a field trip or excursion shall be deemed to have waived all claims against the Charter School or the State of California for injury, illness or death occurring during or by reason of the field trip or excursion. I therefore acknowledge that as a condition of my son/daughter/ward participating in said activity, I hold harmless and waive any and all claims against the State of California, or the Charter School (and its officers, employees, agents), including, but not limited to, claims arising out of any negligence of any officers or employees of the Charter School , for any injury, accident, illness, or death, or any loss or damage to personal property occurring during or by reason of the participation in said activity. I understand this field trip is optional and attendance by my child is not required. I further understand that all students going on this trip will be responsible in conduct to the teachers and other Charter School employees, and, if applicable, adult sponsors at all times. I also understand that the field trip begin and end at the LAX when students meet Charter School employees and that all students are required to go and return from this event on the transportation provided, unless prior arrangements have been made and agreed to in writing by a Charter School administrator and the student’s parent/guardian.

3. Acknowledgment of Risks. I acknowledge and understand that the activities involved in this trip (as detailed in list of trip activities on page 1) may be dangerous and include risks which are inherent and cannot be reasonably avoided without changing the nature of the activity. I acknowledge that participation in the activities can cause personal injury, including emotional trauma and even death.

4. Assumption of Risks. I acknowledge and expressly assume all risks and dangers associated with all field trip activities, whether described above, known or unknown, and inherent or otherwise. I take full responsibility for any injury or loss, including death, which Participant may suffer, arising in whole or in part from the enrollment and participation of the minor Participant for whom I sign, in the activities of the trip.

5. Participant Conduct and Capability to Participate: It is understood that the Participant will follow direction from the teacher(s), chaperone(s) and, if applicable, adult sponsors, at all times. I acknowledge that the Participant is to abide by all rules and regulations governing conduct

during the trip. I certify that the Participant is fully capable of participating in these activities, without causing harm to him/herself or others.

6. Dismissal of Participant. I acknowledge that New West Charter School reserves the right to dismiss any participant from a trip or program that staff believes, in their discretion, presents a safety concern or medical risk, is disruptive, and/or otherwise conducts him/herself in a manner detrimental to the Charter School. Use of illegal drugs, tobacco products or alcohol, or disregarding instructions, rules or regulations are examples of conduct that the Charter School considers detrimental to its program, and that can lead to early dismissal. If Participant is dismissed or departs for any reason, Participant (and his/her parent/guardian) are responsible for all costs of early departure, whether for medical reasons, dismissal, personal emergencies or otherwise. These costs include, but are not limited to, medical evacuation and costs, travel, and compensation and expenses for staff accompanying Participant.

7. Indemnification for Injury Caused by Participant. Parent of minor Participant may be held liable and responsible for any injury or death to another person or injury to property of another caused by the minor Participant, as required by law. I hereby AGREE TO INDEMNIFY (meaning to defend, and to satisfy by payment or reimbursement, including costs and attorneys fees) AND HOLD HARMLESS New West Charter School and its officers, employees, agents, with respect to any claims of injury, death or other loss or damage to person or property suffered by any person arising in whole or in part from the conduct of the minor Participant while enrolled or participating in the trip activity.

8. Insurance. I acknowledge that New West Charter School provides all participants with Field Trip Accident Insurance that covers 100 percent of reasonable and customary charges and is based on individual accidents, without regard to the number of students involved. I acknowledge that in order to make an insurance claim, an accident claim form must be completed, or there must be cooperation with Charter School personnel and the attending physician or dentist in completing an accident claim form, which is available at the Charter School. The claim form shall be submitted in accordance with the instructions on the form. I acknowledge that New West Charter School provides this insurance as a courtesy and in no way is responsible for making, granting, or denying of insurance claims.

I further acknowledge that New West’s student accident policy is an excess policy, and the Participant’s own health insurance should be looked to for primary coverage.

9. Transportation. I acknowledge that each participant is required to go and return from an excursion/field trip by means of the transportation provided, arranged or agreed to by New West Charter School.

10. Medical Treatment/Emergencies. In the event that I, or other parent/guardian, cannot be reached in an emergency, I give New West Charter School staff the authority to obtain immediate medical attention for Participant. I do 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 the medical staff of the hospital or facility furnishing medical or dental services.

11. No Refund. The first two payments for the Washington DC/NY trip are non-refundable and no refund in part or whole will be issued for any reason for these two payments. This includes student suspension, emergencies that require the student to be withdrawn from the trip, mutual agreement between parents and New West that the student should not attend the trip, and any other reason.

Please initial the following:

12. My student is capable of safely riding a bicycle on a tour of Central Park in New York City.____________(initial)

13. My student will conduct himself/herself with respect throughout the trip. My student will adhere to the hotel room and safety procedures outlined by the chaperones. ____________(initial)14. My student will remain with the New West group for the duration of the trip and will not deviate from our itinerary. This includes the flights departing from and arriving at LAX and every event and location on the itinerary. ____________(initial)15. New West cannot accommodate friends and/or family meeting up with or traveling with my student while he/she is on the trip. ____________(initial)16. New West will declare my student ineligible to go on the trip if his or her GPA in the four core classes (English, History, Science, and Math) for the year drops below a 2.0 on or after the date March 18, 2016, in accordance with the school’s promotion policy ___________ (initial)

Student Name ____________________________

Parent Name______________________________

Parent Signature___________________________

Date_____________________________________

Please do not submit this form or payment to the office before November 15th, 2017.

Office Use Only

Submission Date ______________________

Submission Number ______________

Permission SlipIf your student is participating in the NY/DC Trip please return this form and the first

payment to the New West Office.

PARENT/GUARDIAN SECTION: MUST BE COMPLETED

Parent/Guardian Phone Contact During Time of Trip:

Name:

Work Phone: Cell Phone: Home Phone:

Name:

Work Phone: Cell Phone: Home Phone:

Other Emergency Contact:

Name:

Work Phone: Cell Phone: Home Phone:

(Other emergency contact is not used to authorize medical treatment)Physician and Insurance Information:

Name:

Medical Insurance Type and Number:

Phone:

Student Medical Needs for Trip (Allergies/Medical Conditions/Physical Limitations/Medications):[Please be sure to list ALL of the student’s allergies, medical conditions, physical limitations, and medications. Please note that New West Charter School shall not be responsible for knowing anything regarding the student’s medical needs for the trip beyond what is reported on this permission slip.

IF PARTICIPANT IS A MINOR:I acknowledge that I have carefully read this document and understand the information therein. I agree to each of the terms and acknowledgments above, and agree to permit my child to participate in the trip described above.

_______________________________________________ Date:_________________Signature of Participant (Student under age 18)

_______________________________________________Date:_________________Signature of Parent/Guardian (in individual capacity and on behalf of Participant)

_______________________________________________

Parent/Guardian Name (Please Print)

POLICY AND PROCEDURES FOR NEW WEST OUTDOOR FIELD TRIPS

In order to provide for and experience a successful outdoor program, students and participatingadults must take responsibility for themselves, their contributions to the group, and theirparticipation in the outdoor program.

New West staff has identified specific student, parent and adult expectations toensure that individual and group needs can be met.

Participation in the New West outdoor program is optional.It is assumed that every student participating in an outdoor program is doing so by his/herown choosing and agrees to support the goals of the program by contributing in a positivemanner. Students and parents are asked to take steps to become informed about eachoutdoor event by:

1. Reading everything in the trip documents provided

2. Attending all pre-trip meetings

3. Acknowledging that all deposits and trip costs are non-refundable

4. Understand that trip participation is dependent on maintaining both a defined GPA and behavior standards to qualify

If you have questions about any aspect of the program, contact the New West Principal at310-943-5444

It is your responsibility to let the Principal know if you (student and/or parent) haveunresolved questions. At that point, it is our responsibility to make information accessibleand clear.

What is considered inappropriate behavior?Outdoor programs are extensions of regular NWC classes; therefore, ALL schoolpolicies and behavior guidelines apply as if you were on campus. In addition, because ofthe increased level of risk associated with some outdoor activities, goofing off, horseplay,and other actions that jeopardize the safety of individuals and/or the group will not betolerated.

What is the consequence if a participant chooses to behave inappropriately?If students choose to not meet the expectations outlined in the Student Responsibilities section of this guide she/he will be clearly reminded of their responsibilities. If a student still chooses to behave inappropriately after this warning, or behaves in a way that endangers themselves or others, she/he will be sent home from the outdoor program at the parents’ expense. New West faculty make final decisions about a student continuing participation or not.

In the case of student removal, staff will contact parents to arrange transportation home, which may be inconvenient for the parent.

Students and parents are responsible for all expenses related to their removal from a trip, and there are no refunds for students who leave a trip early.

NWC STUDENT RESPONSIBIILITIES CHECKLIST

STUDENTS PLEASE INITIAL EACH LINE

1. ____ Attend any and all pre-trip meetings informational meetings.

2. ____ Be prepared. Bring everything on the clothing and equipment list. Students without proper clothing or equipment may not be allowed toparticipate in the program.

3.____ Stay within sight and sound of the rest of the group or camp at all times, and make sure that an adult knows where you are.

4.____ Communicate openly. Let an adult know if you are not feeling well, havea problem, are cold or over-heated, or feel scared.

5.____ Take care of your living space by respecting equipment, facilities, campboundaries, and quiet hours.

6.____ Be on time for group meetings, meals, and activities.

7.____ Participate with your meal or cooking group in preparing and cleaningmeals. Move carefully in the kitchen area or dining hall to avoid injury.

8.____ Support and respect classmates, adults, and the environment.

9.____ Keep track of and take care of your belongings and rented/borrowed items. NWCMS is not responsible for lost or stolen items, including electronics.

10.____ If you take medications, or will be during the week, you are responsiblefor providing us with the pertinent medication and information in advanceof the trip. Student will give meds to a teacher who will distribute at appropriate times.

11.____ Commit to bringing your best—attitude, respect, care, trust, cooperation--to the experience. Give everything a try!

12.____ Follow all school rules as if you were on campus (as outlined in the studenthandbook). All school policies apply to you while you participate on any trip.

If a student chooses to not meet these expectations or assume their responsibilities, They will be clearly reminded of their responsibilities. If a student continues to behave inappropriately after this warning, she/he will be sent home from the trip at the parents expense