ST. PIUS X REGIONAL SCHOOL 14710 Annapolis Road Bowie, Maryland 20715 301-262-0203 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 needed. Comments:_____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ __________________________________________ ______________________________________ 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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