25,2016 Ranch 412712016 412512016

MESA PUBLIC SCHOOLS STUDENT TRAVEL _ ELEMENTARY DIVISION
PARENT/GUARDIAN PERMISSION FORM
Durc1211112016
s"1,oo1 Red Mountain Ranch
25,2016
sn Monday, April
x,. Fifth Grade
is
The putpose
Prescott Pines
ofthe tral'el/activity is
outdoor Education- science camp
(Sitc)
(Primary O$ective)
we wilr be leaving school at
wi11be providea
planning student travel/activity to
((1rss, Grade or Cr0uD)
(Day of Week/Date)
10 00am on
412512016
and retuming
(Time/Date)
6, 2:45PM on
412712016
Transporahon
(TimelDate)
u, Coach Bus
sartL!n'hrsr'q!trPdrorMondav'rhecosrorrherprs$13srorsrldenrsahdr
Other-details(ifapplicable):
School Bus or Van, Walking. Other (if "Other," see attached)
Please return this permission
form to the school no later ,6un
Teri Nowicki
JanUary 22, 2016
472-7901
472-7951
(School CoDtact)
(Emcrgency Contact Number for Day of Travcl)
(School Phonc Number )
PARENT/GUARDIAN PERMISSION
I do not want my child,
to participate in the student tlavel/activity described above
(Print First and Last Namc of Child)
My child,
has my permission to palticipate in the student
(Print
first
travel/activity described above.
and Last Name of Child)
LUNCH (Please check. if necessary)
U
tr
El
l wrr pacK a sacK runcn.
I request that the school use
a
punch on my child's lunch tickct fbr a cafeteria sack lunch.
a cornmercial lunch, if pernritted by the school.
My child will bdng money sufficient to prlrchase
MEDICAL TREATMENT AUTHORIZATION
(Parent/guardian signature indicates the parent/guardian has read and approves the medical treatment authorization.)
In the event ofillness or injury occurring to nry child while on this travel/activity, I hereby give my consent for rnedical or dental care deemed necessary by the
attending health care provider or dentist. My child may be examined and any necessary procedures (n-redical, dental or surgical), anesthesia, or diagnostic
procedures (1ab or x-ray) may be performed under the supervision of a member of tlie hospital or medical office staff fumishing such services. I further
acknowledge that I am financially responsible for any medical, dental, ambulance or other' health cale expenses or transporlation of my child home, which
mightoccurasaresultofsuchillnessorinjury. Ialsoacknowledgethatlmayobtainaccidentinsurancethroughtheschoolnurseifldonotcurrentlyhavefamily
medicalinsurance. Iunderstandthat,intheeventofotherthanminorillnessorinjury,reasonableefforlwillbemadetocontactme.
Horne Phone
Hours:
:
Please PRINT narne ofPalent or Guardian
Work Phone:
Hours:
Cell Phone:
Houls:
SIGNATURE - Parent or Guardian
Date
STUDENT RIDING IN PRIVATE VEHICLE
When district tl'ansportation is plovided or a private vehicle is artanged for by a school en-rployee, the parent/guardian may instead drive the student or
allow the student to ride with another adult if pemission is indicated below. Where trar.rsportation is provided by an adult in lieu of transpe$4lipn
provided for or arransed by the district. the district has no responsibilitv for the s
drivel ofthe vehicle has proper license and insurance.
tr
I will drive my student and
to and from the above activity.
Q.Jame(s) of Riding Student(s).
if
applicablc)
(Driver's Name)
FAILURE TO GIVE PERMISSION RESTRICTS THE STUDENT TO TRANSPORTATION PROVIDED FOR OR ARR-ANGED BY THE SCHOOL.
SIGNATURE - Parent or Guardian
Date:
Revised
07 /01
l0'7
Please PRINT name of Parent or Guardian