ST. PIUS X REGIONAL SCHOOL
                 14710 Annapolis Road  Bowie, Maryland 20715

I request that my child,__________________________________,be allowed to accompany the____ grade from St. Pius X
Regional School on a planned trip to ________________________.
The educational objective of this trip is ____________________________________________. We will leave the school on
_____________at ____________ and return by ______________.                 Our transportation will be provided by the
_________________________________ Bus Company. The cost (non-refundable) of this trip is________________. Checks
should be made payable to St. Pius X School. The required attire is______________________________________________.

Field trips, though an extension of our education program, are a privilege, not a right. Students are expected to be cooperative
and behave according to the school standards.

I hereby request that my child,___________________________, participate in the event described above. I understand that
this event will take place away from the school grounds. I give my consent to the conditions stated above for my child’s
participation in this event, including method of transportation. I know that all possible care and safety will be provided for my
child. Therefore, in case of an accident, I will not hold St. Pius X Regional School and/or its faculty responsible.

During the field trip, I may be reached at ______________________________________(address)
_____________________(phone number). If I cannot be reached in the event of an emergency, the following person is
authorized to act on my behalf:
Name ________________________________                   Relationship to student ________________
Address ______________________________                  Phone number _______________________

Physician’s Name and Phone Number _______________________________________________

Please check one of the following and complete the comment section if needed:
     No prescribed medication need be sent with my child on this field trip.
    Prescribed medication (including inhalers and epipens):______________________________________________
                                                                                Name of Medication(s)
should be sent with my child on this trip with instructions about who will accompany the student to administer the medication if

__________________________________________                       ______________________________________
Signature of Parent/Guardian                                     Signature of Teacher

I would like to chaperone.   □ Yes     □ No        Daytime Phone Number:____________________________

Please complete this form and return to your child’s teacher by ___________.

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