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LOUDO!

-Jl\] CCIU IiITY PU sLIC SCHOOLS


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
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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.
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Purpcse ofTrip: Se e a theatrical repi'esentatioil of chilclren's literature. Correlates with First Grade Reading and Language Arts SOLs
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(t.I, Risks lnvolved: (check all that apply to trip) Transportation (check all that apply to trip) Drir,,ers of Prir:ate or Leased
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ul !:$ n Amusement/Theme Park Activlties tl watl<ing Vehicles (check all thatapply)
:,:::::,,t:.
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
tl
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$ 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
l:PAR"IlClFANTANDEMERGENcY|NFoRMAIloN:'.
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): ( )


:::!::!!lii:i
:,:::::::::::
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):

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Describe any rnedical condition/s or special needs of the above named student:
L

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


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

::::::(tr,
Name of tlealth lnsurance Company: Phone Number (w/Area Code):
Insurance Poticy/Member
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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
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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.
n- PARENTAL PERMISSION AND AGREEMENT :i ,:i,::l:
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1.
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
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my child to travel and fully participate in all aspects ofthe trip.
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2.
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
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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

**SIGNATURE INDICATES AGREEMENT WITH ALL CONDITIONS LISTED ABOVE**

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