Museum of Science Industry Permission Slip
Science Works Field Trip 📅 Date: Saturday, October 10, 2026 🕙 Time: 9:30 AM – 3:00 PM 🚌 Departure Location: Project Impact 180, 1624 S. Pulaski, Chicago, IL 60623 Departing@10AM | Returning 3PM 📍 Event Location: Museum of Science and Industry, 5700 S. DuSable Lake Shore Drive, Chicago, IL 60637 Join us for an exciting day at the Museum of Science and Industry for Science Works! Youth will explore cool jobs and hot careers in science, technology, engineering, and math (STEM) through hands-on activities, inspiring speakers, and one-on-one conversations with professionals in the field. Transportation is free, and families are encouraged to attend. Spots are limited, so register today to secure your seat!
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's #1 Full Name
*
First Name
Last Name
Child #1 Age
*
Please Select
5
6
7
8
9
10
11
12
13
14
15
16
17
Child #1 T-shirt Size ( T-Shirts are available for purchase $15. NOTE: THE BLUE SHIRT IS REQUIRED ON THE FIELD TRIP for PI180 Participants!) Submit payment Cash App $ProjectImpact180 or Zelle: info@projectimpact180.org. Place child's name in the memo session
Please Select
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
I need to reorder a shirt - The cost is $15
Child #1 School
*
What school does the child attend?
Youth #1 Grade (Youth under 5th grade may not attend without a parent or guardian. Parent is responsible for own expenses)
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Child's #2 Full Name
First Name
Last Name
Child #2 Age
Please Select
5
6
7
8
9
10
11
12
13
14
15
16
17
Child #2 T-shirt Size ( T-Shirts are available for purchase $15. NOTE: THE BLUE SHIRT IS REQUIRED ON THE FIELD TRIP for PI180 Participants!) Submit payment Cash App $ProjectImpact180 or Zelle: info@projectimpact180.org. Place child's name in the memo session
Please Select
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
I need to reorder a shirt - The cost is $15
Child #2 School
What school does the child attend?
Youth #2 Grade (Youth under 5th grade may not attend without a parent or guardian. Parent is responsible for own expenses)
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Which Organization is your child affiliated with?
*
Project Impact 180
BBF
LCA
Other
Name of Parent/Guardian
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I, the parent/guardian of the student named above, agree with the following statements:
*
I hereby give permission for my child to take part in the trip described above.
I understand that I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child(age 10+) shall be accompanied by staff member(s)/ volunteer(s) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site.
I understand that my child is expected to behave responsibly and adhere to the discipline code and policies set by MSI  and Project Impact 180.
I acknowledge and accept responsibility for my child's actions and release Project Impact 180, its board members, staff, affiliates, volunteers, and any associated partners from all claims and liabilities arising in connection with this trip, except in cases of negligence by Project Impact 180 staff.
I confirm that my child is medically fit and able to participate in all activities at MSI .
I understand that as a parent, if I believe it is necessary to limit my child’s activity to a great extent, then Project Impact 180 may not be able to accommodate my child on this trip and that I and my child will be informed of this decision as soon as possible upon the receipt by the school of this completed consent form.
I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
I understand that alcoholic beverages and/or illegal drugs are prohibited and have discussed this prohibition with my child. I understand that if my child is found in possession of these substances, he/she will be subject to disciplinary procedures that may impact future trips with Project Impact 180.
I understand that students who violate the discipline code set by MSI and Project Impact 180 may be excluded from participating in future Project Impact 180 trips.
I have indicated below any permanent or temporary medical or other condition(s) including special dietary and medication needs, or the need for visual or auditory aids, which should be known about my child: (please write "N/A" if this does not apply to your child)
*
Emergency Contact Name:
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Additional Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Bag lunches will be provided by Project Impact 180.
*
Turkey
Ham
Will bring my own lunch
Are you interested in joining us as a chaperone? (We are limited to only a few chaperones per trip so we will confirm with you once we receive responses. Also, please note that chaperones will be responsible for paying all trip fees. If you have small children who require supervision, you cannot serve as a chaperone due to the attentiveness needed in a large space.
*
Yes
No
Submit
Signature of Parent/Guardian
*
Should be Empty: