Belevedere Permission Slip

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MARY ELLEN HENDERSON MIDDLE SCHOOL A Falls Church City Public School 7130 Leesburg Pike Falls Church, Virginia 22043 (703) 720-5700 Fax: (703) 720-5710 FIELD TRIP RELEASE FORM Name of Student: _______________________________________________

Permission slip and money are due by: Wednesday, 10/6/2010 Activity: Maize Maze and Pumpkin Patch Place: Belvedere Plantation Teachers Responsible: 7th grade teachers Date: Monday, 10/11/10 Mode of Transportation: Charter bus Time Leaving:

8:30 AM

Time Returning: 2:00 PM

Acknowledgment of Liability My student has my permission to go on this field trip and participate in the activity described above. I understand that the necessary safety precautions will be taken for the supervision of my student. The school has my permission, in an emergency when I (or my physician) cannot be contacted, to take my student to the emergency room of the nearest hospital, and the hospital and its medical staff have my authorization to provide treatment which a physician deems necessary for the well-being of my student. I have read this waiver and do not have any questions about the words used or their meaning. Signature of Parent/Guardian: _____________________________________________

Date: ___________________________ Telephone Number: ______________________

Physician: ________________________Telephone Number: ______________________ My child will bring a lunch My child will need a bagged lunch from the cafeteria for this trip. (note: this may not apply for all field trips if students are eating lunch prior to leaving for the field trip) Lunch #: _______________ Check here if you are interested in sponsoring a classmate for this field trip. Please include you sponsor donation in with your child’s field trip payment. Check here if you are interested in being a chaperone for this trip. Phone #: ___________________ Please contact the teachers responsible, if you are need of financial assistance for your child for this trip. Ann M. McCarty Principal

Jeanne Seabridge Assistant Principal

Janae Rittenhouse Guidance Coordinator

Matthew Sowers Counselor

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