Secondary School Student Trip Information and
Permission Form
Date
of trip: 12-18
Destination:Culpeper
Regional Hospital
Educational
Objective(s):To perform for the Culpeper Regional Hospital
Departure time from
school: 1:45 Return time: 2:45
Nonrefundable cost to be incurred by the
student:0
Nonrefundable cost to be incurred by the attending
adult:0
Make
checks payable to:N/A
Other
important information including: use of electronics, student dress, souvenir
shops, supplies needed:
Keep the top half for your
information. Return the bottom half to
the appropriate teacher or staff member.
.
Please
list any serious allergies or medical
conditions of your child:
_______________________________________________________________________.
My child, ______________________________ has permission to attend
the trip to __________________ Culpeper Regional Hospital_____________in
Culpeper, VA on ______Dec. 14th__________ (date).
I give prior permission for
any emergency medical treatment of my child where a delay could cause
significant harm to his or her health.
________________________________ __________
Parent/Guardian’s Signature Date
Parent
and Emergency Contact Name__________________________ or
__________________________
Phone
Numbers: ________________ or ___________________ or_______________
