Secondary School Student Trip Information and
Permission Form
Date
of trip: 12-20-13
Destination:
Pearl Sample Elementary and AG Richardson Elementary
Educational
Objective(s): To perform at Pearl Sample and AG Richardson Elementary
Departure time from
school: 8:30am Return time: 2:15pm
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:
See
information sheet
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 Pearl Sample Elementary and AG Richardson Elementary in Culpeper,
VA on December 20, 2013.
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_______________
