PERMISSION SLIP

Dear Parents/Guardian, September 10, 2013

We would like to invite your child for a field trip to the Griffith Observatory on September 27, 2013. Students will
learn more about the stars, planets, and the universe through this field trip. The Griffith Observatory features fantastic
special exhibits that change all the time. It also offers fun and informative exhibits presented in an interactive world. Also
you can get more information from the official website of this great place: http://www.griffithobs.org/

The due date to return the signed permission slip to Ms. Maria is Friday, September 20, 2013.

When: Between 10:30 am 3:00 pm on Friday, September 27, 2013
Where: Griffith Observatory
2800 E Observatory Ave
Los Angeles, CA 90027

Who: 6
th
, 7
th
and 8
th
grades
Cost: Cost of transportation and tickets: $8 (Please see below)

Please check one:
I have included a $8 donation to cover the cost of the field trip
I have included a larger/smaller donation to help other students attend. The amount is: ________________
I am unable to pay $8. Please send my child information to fill out for a scholarship to cover the cost.
Students can bring extra money to buy souvenirs.
Due to parent-teacher conference on Sep.27
th
there is no afterschool program.
We, the parents/guardians of the student named below, understand the nature of the student activity being planned
to the Griffith Observatory. We understand that supervision and transportation will be taken care of by MSA-6.

Release from Liability, Assumption of Risk and Indemnity Agreement

All participants, including chaperones, in the activity described below must read and sign this agreement. If the
participant is under 18 years of age, a parent or guardian must read this agreement, agree that the minor may
participate in the activity described below and sign the agreement on the minors behalf. The minor must also read and
sign this agreement.

1. RELEASE FROM LIABILITY. For and in consideration of permitting __________________________ (the
name of the student) to participate in the voluntary and non-school sponsored activity during the 2013 to 2014 charter
school year, I hereby voluntarily release, discharge, waive and relinquish any and all claims or causes of action, including
but not limited to negligence and strict liability, for personal injury, property damage, or wrongful death arising from the
Participants participation in, or activities related to, the Activities against Magnolia Science Academy and/or its officers,
agents, employees or volunteers (collectively Magnolia Science Academy 6 ). I also expressly agree to release,
discharge, waive and hold harmless Magnolia Science Academy 6 from any act or omission of negligence in rendering or
failing to render any type of emergency or medical services. In signing this agreement, I fully recognize and understand
that if I am injured, die or my property is damaged; I am giving up my rights (as well as the rights of my heirs, executors,
administrators or assigns) to make a claim or file a lawsuit against Magnolia Science Academy 6 even if they negligently
or by some other act or omission cause the injury, death or damage.

2. ASSUMPTION OF RISK, INCLUDING NEGLIGENCE. I hereby acknowledge I have voluntarily chosen to
participate in the Activity. I understand that while Magnolia Science Academy 6 may be making arrangements related to
the activity but this is not a school-sponsored activity. I understand that many activities during the field trip may have
risks and hazards where injury, death or property damage can occur. I understand there are risks in going on the field
trip, including but not limited to injury, death or property damage. Additionally, I understand that emergency medical
services may not be available during the field trip. I hereby acknowledge that I intend to assume all risks and to
exempt, release and relieve Magnolia Science Academy 6 from any and all liability, including strict liability, for personal
injury, property damage, or wrongful death, including that caused by negligence.

3. INDEMNIFICATION AND HOLD HARMLESS. I, for myself, my heirs, executors, administrators or assigns,
agree to hold harmless and indemnify the Magnolia Science Academy 6 from any and all claims, including any and all
defense costs, (which shall include attorneys fees), incurred in connection with the claims for bodily injury, wrongful
death or property damage, sustained by me, or in connection with claims for bodily injury, wrongful death or property
damage sustained by third parties which may have been caused by me, whether negligent or not, in the course of my
participation in the Activity.

4. PARTICIPANTS RESPONSIBILITIES AND REPRESENTATIONS. I hereby agree to follow all rules, regulations,
and instruction of Magnolia Science Academy 6 while on the Activities. I also represent that I am physically and mentally
capable of participating in the Activity.

5. CALIFORNIA LAW AND VENUE. I agree that this agreement shall be governed by and construed in
accordance with California law. In the event any legal action is commenced to enforce or interpret the provisions of this
agreement, the venue for any such action shall be in the State of California. The courts or laws of any other state of the
United States, United States Federal courts, or the courts of any other nation, shall not have jurisdiction over this
agreement and the enforcement of its provisions.

I acknowledge that I have read the foregoing Release from Liability, Assumption of Risk and Indemnity
Agreement, and I am fully aware of the potential dangers and risks inherent and incidental to participating in the trip. I
am fully aware of the effect of signing this written instrument. I voluntarily sign my name as evidence of my acceptance
of the above provisions.

______________________________ _____________________ __________________________
Student Name (Please print) Parent or Guardian Name Signature of Parent or Guardian

____________
Date

Cell Phone: (_____) ______________ Home Phone: (______) _______________

Work Phone: (______) _______ ___

Required medications: ________________________________________________________________
Please check below IF your child has:
_ Asthma _ Diabetes _Kidney Injuries _Seizure Disorder _Heart Condition
_Other Medical Condition: __________________
Medications: __________________________________________________________________________
If the student requires medication, I understand that I am obligated to ensure that the medication and the Medication
Authorization Form is on record in the MSA-6 Front Office.
Email: mhuezo@magnoliapublicschools.org