Get Field Trip Release Form

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 Friday 3/1/13 Activity InnerQuest Place Medeira School McLean Virginia Teachers Responsible 7th Grade Teachers Date Thursday 4/4/13 or Tuesday 4/9/13Mode of Transportation School bus Time Leaving 10 00 am Time Returning 5 00 pm Students must arrange for transportation home from MEHMS 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 from home My child will need a bagged lunch from the cafeteria for this 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. Please contact the teachers responsible if you are need of financial assistance for your child for this trip* Seidah Ashshaheed Principal Jeanne Seabridge Assistant Principal Alyssa Jacobson Guidance Coordinator Matthew Sowers Counselor Elise Kenney. 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. 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 from home My child will need a bagged lunch from the cafeteria for this 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. 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 from home My child will need a bagged lunch from the cafeteria for this 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. Please contact the teachers responsible if you are need of financial assistance for your child for this trip* Seidah Ashshaheed Principal Jeanne Seabridge Assistant Principal Alyssa Jacobson Guidance Coordinator Matthew Sowers Counselor Elise Kenney.