DR. WILLIAM H.

HORTON ELEMENTARY SCHOOL

Dr. William H. Horton Elementary School

291 N. 7th Street
Newark, New Jersey 07107

Trip Date:
Time:
Trip To:

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Return this form no later than:
Student Name: ____________________________________ Teacher/Homeroom: ___________

It is hereby requested that the above-mentioned pupil be permitted to take this trip, and in consideration of such
permission, it is agreed by the undersigned as follows: Neither the District nor any of its employees shall
assume any responsibility for any intentional conduct of the students that result in a claim arising out this trip.
All claims for intentional conduct are hereby waived. The undersigned will indemnify and save harmless the
District and its employees from liability, for claims arising out of intentional and/or contributory negligent
conduct of the student and as against the District and its agents and employees. “Trip” includes the period
between the time when the pupil leaves the school and returns home.

In addition, I hereby grant the Newark Board of Education, Dr. William H. Horton School and their agents the
absolute right and permission to use photographic portraits, pictures, digital images or videotapes of My Child,
or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any
lawful purpose whatsoever, including but not limited to use in any district publication or on the district related
websites, without payment or any other consideration. I hereby waive any right that I may have to inspect
and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child’s
likeness appears, or the use to which it may be applied.

I waive all claims against the Board of Education and its employees for anything that occurs during the
mentioned trip.

Parent/Guardian Signature: ________________________________ Date: ___________________________

Parent/Guardian Name (print) _______________________ Emergency Number: _______________________

Student Name: ___________________________________ Daytime Class #: __________________________

Trip Date:
Time:
Trip to:

765 Broad Street • Newark, NJ 07102 • 973-268-5268 • http://www.nps.k12.nj.us

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