Editing previous response:

Please fix the highlighted areas below before submitting.

5th & 6th grade field trip permission slip

Location: Lackawac Sanctuary

Date: October 21, 2024

Departure & Return times: Leaving school at 8:30 a.m. and arriving back at school at 2:30

Cost: $8 per student

Lunch: Bring a bagged lunch

Dress Code: Jeans, or long pants (no leggings), a t-shirt, sneakers/hiking shoes, and a jacket.

Transportation: Bus

Chaperones: The trip will be chaperoned by Mrs. Hughes and Mrs. Brown

Emergency Phone numbers: Mrs. Hughes (570) 418-5112 and Mrs. Brown (570) 470-1544

Student First & Last Name*

Answer Required

Grade*

Answer Required

Parent/Guardian First & Last Name*

Answer Required

Parent/Guardian Phone Number*

Number Required

Emergency Contact Name*

Answer Required

Emergency Contact Phone Number*

Number Required

Family physician*

Answer Required

Family physician phone number*

Number Required

Special medical conditions:

Answer Required

Credit/Debit Card Payment for student

Answer Required

$8.00

Payment by cash or check

Answer Required

$8.00

I give my consent as the parent or guardian of the above named student to participate in this event. In doing so, I agree to the following:

In case of a medical emergency, I grant the chaperones the right to authorize medical care, if none of the persons named above can be reached.
I agree to pay the expenses of returning my child home before the end of the event if he or she does not adhere to the established standards of conduct.
The school is not responsible for damage or loss of property personally owned by my child.

Parent/Guardian Signature*

Signature Required

Note for teacher:

Answer Required

Confirmation Email

Confirmation Email *

Email Required