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sct-!001 DAy A1.JD EXICrui.'rI) rlAy FI{LD Tfrtp p[frhit5sjs,u f c{li,t
lnsiructio_ns: This foim and an attached fielC trip description (1) must be provlcled for each stLrdent (K-12) participatiilg rn an
LCPSfieldtriporseriesofVIiSLactivities,and(2) mustbewiththevehicletransportingthestudentnanred. (3) l'heTrip
Organizeri,vill completeSectionlandprovideacopytoeachstudentparticipant, (4) Sectionll istobecompletecl andslgnedby
the student's parent/guardian and returned to the Trip Organizer,

Fl[,LD TftlP ItiICfiF,iA-i lOli]5ee attacheci Dcscription and ltincrery

Scl:ool lJanre: Lucketts Elemeniary School Today's Dat*: g/r4/L7 | Permission Due Dste: Ogl?gll7
Class/6rade/or Ciub Participating: First Narnc of Trip Organizer: S. Bickmore
:,,t riag
Tit!e or Position: First grade teacher
:9 Destinaticn(s): Weinberg Center for tlre Arts, Date, Time and Place cf Departure 10/05/L7 8:3C a.m.
Bal<er Perl< Frederick, It4D and Bal<er Park, Fredorick, ItlD Date, Time and Place of Pef{rr, filo5lf7 L:15 p.m.
Purpcse ofTrip: Se e a theatrical repi'esentatioil of chilclren's literature. Correlates with First Grade Reading and Language Arts SOLs
:( F
(t.I, Risks lnvolved: (check all that apply to trip) Transportation (check all that apply to trip) Drir,,ers of Prir:ate or Leased
ul !:$ n Amusement/Theme Park Activlties tl watl<ing Vehicles (check all thatapply)
n SwimPning/Boating/Water Activlties A School Bus il Parent
ii; {) D Athletic/SportingEventParlicipation f] Commercial Charter Bus/Metro Bus or Rail E Teacher or Staff l,4cmber

$ X Outdoor Activities/Ropes Course School Vehicle il chaperone/otherAdult

,i,::'.i) U other (describe): tl Private Vehicle Vehicle Type (check all that apply)
n Leased Vehicle
fl Car
tr None-Parents or Participant will be responsible for
L] van (10 passengcr or less)
transportation to and from the acti,/lty.
fl other
Student's Full Name;

Full Name of Parent(s)/Guardian(s):

Home Address of Student (include number, street, city, state & zip code - NO P.O. Boxes):

Home Phone (w/area Code): ( ) Cell or Work Phone (w/Area Code): ( )

Emergency Contact f1-Name and Relationship : Phone Number (w/Area Code):
Phone Number (w/Area Code):
Emergency Contact S2-Name and Relationship : Phone Number (w/Area Code):
:::: {!
:ltt () Phone Number (w/Area Code):

,t: ,tS
Describe any rnedical condition/s or special needs of the above named student:

iiti:::rc Name of Child's Primary Care Physician:

,:lt:ll:.4, Phone Number (w/Area Code):

Name of tlealth lnsurance Company: Phone Number (w/Area Code):
Insurance Poticy/Member
o I L"r'tn
r& For Secondary School Extended Day Field Trips Only: Do you give permission for your child to receive Tylenol or its generic substitute while
on this field trip? (ege/weight appropriate dose witt be given.) Ves no L I
O3 FIEID TRIP MEDICATION NOTE: On field trips that occur during the length of the school day, any prescription medication already provided to
the school will be carried and administered by Loudoun County Public Schools staff. On Extended Day Field Trips, additional physician's orders
L andparental permissionmayberequiredformedicationthatistobegiven. Pleasecontacttheschool nurseorhealthclinicassistant.
r':::i: :,

I understand that participation in this field trip is voluntary that it is not required, and that it exposes my child to some risk. I have read
:d) and understand the attached travel itinerary or VHSL schedule and the description of the activities involved, and I give my permission for
my child to travel and fully participate in all aspects ofthe trip.
I understand that LCPS will not be responsible for personal property that may become lost or damaged during the trip and that LCPS
o does not provide medical or accident insurance for student illness or injury which may occur while on the trip,
(, 3.
-o ln case of emergency, I authorize and give permission for my child to receive first aid, 911 emergency medical care and transport, or to
o havethedesignatedemergencycontactpickupandtransportmychildtoaphysicianorhospital. lunderstandthatlwillberesponsible
for any related medical bills, fees, or costs Incurred.
4, I understand that non-refundable tickets purchased by parents/students will NOT be reimbursed if the trip is canceled due to inclement
weather, hazardous conditions, or if conditions make it inadvisable to have students on a trip, LCPS wilt provide as much advance notice
as possible of any cancellations.
5. I understand that during a middle or high school field trip that there may be periods of time when my child will not be supervised by an
adult, but he/she will be required to adhere to check-in times with a chaperone, and that all regular school rules and regulations apply
during the field trip.
Parent Signature Date


LCPS School Day and Extended Day Field Trip Permission Form Page I of 1
Edition: luly 18, 2012