HIGH SCHOOL FIELD EXPERIENCE PERMISSION FORM– DUE BY FRI, Sept, 30, 2016.

Trip: Jarrell Plantation Historic Site

Teacher Name: Bradford, Jihan/ Adams, Joseph/ Fenn, Frank/ Theodocion, KelleySubject Area: Social Studies

Student Name: ______Grade: ______Age: ______

Student Address: ______

Zoned School of Attendance ______

Departure Date/Time: Thursday, October 20, 2016 @ 9:00am Sharp!!!

Departure Location: Impact Academy, 330 East Tomlinson Street, McDonough, GA 30253

Itinerary:

10:00am – 11:30am: Jarrell Plantation

11:45am – 12:30pm: Lunch at local fast food site

12:45am-2:00pm: Return to Impact Academy

2:00pm- Arrive at Impact Academy

*Lunch will cost approx. $10.00, bring on the day of the trip. Students may choose to bring their own lunch.

Trip Cost: $15.00 - Bring FORM & MONEYto Mrs. Capell in the IA Admin Office by Friday, September 30, 2016.

Transportation will be provided by HCS bus transportation.

This section to be completed by parent/guardian. Please complete form and return to IA Office.

Emergency Contact(s) [please PRINT]: ______,______

Best Number(s) for Contact(s): ______, ______

Check ALL that apply:

____My child has permission to attend the field trip.

____I will help chaperone the trip (an additional $15 per adult is included in the payment). Parent may drive and pay own parking.

  • Students must ride the bus to the venue, but may ride home with their parent only.

____ My child will bring $10 for lunch at a local restaurant - OR ____ My child will bring their own lunch.

____My child has medication that should be administered during this trip. If so, what is his/her medical condition? ______

____My child requires transportation accommodations. Please be specific. ______

CONSENT

If any emergency medical/procedure/treatments are required by the student during the trip, I consent to the trip’s supervisor taking, arranging for, or consenting to the procedure or treatment at his or her discretion. I further release and waive any claim which or any other person, firm, corporation, or entity may have or claim to have, known or unknown, directly or indirectly, from any losses, damages or injuries arising out of, during, or in connection with the student’s participation in the activity, any trip associated with the activity, or the rendering or emergency medical procedures/treatment, if any. I further agree to indemnify and hold harmless and reimburse the HenryCountySchool District, the Board of Education, its successors and assigns its members, agents, employees, and representatives thereof, as well as the trip supervisor from any and all claims and losses.

______

Signature of Parent/GuardianDate