Fillable Off-Site/field Trip Permission Form - Xavier High School printable pdf download

Off-site/Field Trip Permission Form

School/Parish/Program Name: _____________________________________________

Date

Person in Charge: ___________________________________________ Grades: ______________

Event and Purpose: _________________________________________________________________

Date(s) of Event:__________ Departure Time:_____________ Time of Return:______________

Cost of the Event: _____________________ Form of transportation: ________________________

If private passenger autos (volunteers) are specified, will you be able to drive?

________

Yes*, I will be able to drive and accommodate ___ students (a seat belt is required for each student and no child

is to be seated in the front seat of a car equipped with a passenger side airbag, unless old enough according to

manufacturer’s recommended age.) *Drivers will be notified after all slips are returned.

Section 1 - By signing this section, I (parent/guardian) certify that I request and give my permission for

________________________________________________ (

to attend this

name of student/participant)

event. Further, I have previously completed the Annual Parental/Guardian Consent Form and Liability

Waiver and agree to the conditions as set forth.

Parent/Guardian Signature:__________________________________________ Date: __________

Contact Phone number(s) ____________________________________________________________

Section 2 - Nonprescription Medication Permission - By signing this section, I hereby grant permission

for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my

child.

Parent/Guardian Signature:__________________________________________ Date: __________

Section 3 - Please list (continue on reverse side if needed) any medical information important for the

adult in charge to know and/or any changes in this child’s medical condition or emergency contact

information since the completion of the Annual Parental/Guardian Consent Form and Liability Waiver.

________________________________________________________________________________

Archdiocesan Policy 5141 covers the administration of prescription medication; contact the program

administrator for additional information.

Please return this permission slip by____________________________________________________

Supervisor’s Signature

_________________________________________________________________________

(Principal, C/DRE, Youth Director, Pastor, etc.)

This is the only permission slip that will be accepted for this Event

Please detach and save for your information/reference

Person in Charge: ___________________________________________ Grades: ______________

Event and Purpose: _________________________________________________________________

Date(s) of Event:__________ Departure Time:_____________ Time of Return:______________

Cost of the Event: _____________________ Form of transportation: ________________________

Edition: 080108

Off-Site/field Trip Permission Form - Xavier High School