Release of Student to Parent/Guardian After Field Trip or Activity
FORM 3204-2

I request that 	 at 	
Student Name	School
be released to my custody after 	 on 	
Trip/Activity	Date

at 	
Location of Event/Pick up Point
rather than returning to school in the transportation provided by Clovis Unified School District (District).
The following are additionally authorized individuals (also listed on Form 11-S Student Release Authorization on file at school site) to whom the above-referenced child may be released:

Name	Relationship

Name	Relationship

Name	Relationship

Waiver of Claims:
I agree that once my son/daughter is released to my custody, I assume full responsibility for his/her health, safety and welfare and as provided for in California Education Code Section 35330. I agree to waive all claims against the District and hold the District, its officers, agents and employees, harmless from any and all liability or claims, which may arise out of or in connection with my child’s participation in this activity. This waiver shall not apply to any occurrences which may arise solely out of the negligence of the District, its employees or agents.

Printed Name (Parent/Guardian)	Approval Signature (Parent/Guardian)

Home Phone Number	Other Phone Number	Date

It is the responsibility of the designated school official to ensure all students are properly accounted for before transportation to or from a school activity occurs.

Adopted: 3/24/10 Revised: 9/20/10

Form 3204-2	Page 1 of 1