PERMISSION SLIP

PERMISSION SLIP

Field Trip Authorization Form and Medical Information

General Itinerary/Destination	{generalItinerarydestination}
Date(s) of Trip	{datesOf32}
Staff Chaperone(s)	{staffChaperones}
Transportation	{transportation}
Cost	{cost}

General Itinerary/Destination
Start Date

MonthDayYear
Date
Date(s) of Trip
Staff Chaperone(s)
Transportation
Cost
Type a question
Student Information
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Student Age
Student Cell Phone #
Please enter a valid phone number if applicable.
Emergency Contact Information
Primary Guardian(s) Name*
Primary Guardian Phone Number*
Please enter a valid phone number.
Secondary Guardian(s) Name
Secondary Guardian Phone Number
Please enter a valid phone number.
Other Emergency Contact(s)
Other Emergency Contact Phone Number
Please enter a valid phone number.
IF TRANSPORTATION is NOT BEING PROVIDED BY SCHOOL: The student named above

is allowed to drive themselves to or from the site. STUDENTS CANNOT DRIVE OTHER STUDENTS.is allowed to ride with an adult driver from the Baxter Academy community.will be transported to and from the site by family or family designee.
In consideration of the opportunity for my child to participate in this field trip, hereby release Baxter Academy for Technology and Science and their agents and employees from any liability, claims, demands, and cause of action whatsoever arising out of or relative to any loss, damage or injury that may be sustained by my child. I understand the arrangements and believe that the necessary precautions and plans for the care and supervision of my child during the field trip will be taken.

In the event that a student violates the drug, alcohol, tobacco, or safe school policies or commits any significant offense during this trip, school authorities will notify the parents/guardians immediately. The parent will be expected to provide for the student's immediate return home. A school-assigned consequence will follow. Please review the above behavioral contract and talk with your student about your expectations for appropriate behavior.
Primary Guardian Email*
example@example.com
Primary Guardian Signature*

Clear
Date

MonthDayYear
Date

	Name of Medication	Dosage	Time
#1
#2
#3

PERMISSION SLIP

Student Information

Emergency Contact Information

Health Information