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: _____________________________________________
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