LITTLE SCHOLARS of ARKANSAS “Embrace your ... - LISA Academy

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					            21 Corporate Hill Drive                                                   Telephone: 501.227.4942
               Little Rock, AR 72205                                                     Fax: 501.227.4952

                                   LITTLE SCHOLARS of ARKANSAS

                                               “Embrace your Future”

                             Sophomore College Visit Permission Slip
Date permission slip is given: Monday, February 27, 2012
Date permission slip is due: 5:00 pm, Friday, March 9, 2012
Date and time(s) of the event: May 21, 2012, 09:30am – 1:00pm
Fee: N/A
Place: University of Central Arkansas
I pledge to abide by all policies of the Lisa Academy handbook. I understand that I am governed by the same rules on
this event as when I am at school. Any failure to adhere to these policies will result in disciplinary action.

Student’s Name: ____________________________________
Student’s Grade/Section: ______________________________
Student’s Signature: _________________________________

This is to certify that the above mentioned student has my permission to go on the field trip listed with this group. I (we),
the parent/guardian(s) of the aforementioned student understand and agree that the trip is a school sponsored activity.
This release is intended to cover all injuries of every name, type, kind or nature, and personal property damage, if any,
which may be sustained or suffered from any cause connected with or arising out of, or from participation in the listed
events. All necessary precautions will be taken. I understand I am responsible for transportation costs if my child is
required to return home for disciplinary measures.

Parent/Guardian Name: _______________________________
Signature: _____________________________ Date: _____________

                                         Emergency Medical Release Form

Address: ________________________________________________________________________
Home Phone: _________________ Work Phone: _______________ Cell Phone: _______________
Emergency Contact/Phone: __________________________________________________________
Insurance Company/Policy/Group #: __________________________________________________
Doctor’s Name/Number: ____________________________________________________________
Blood Type___________________ Known Allergies: _____________________________________
Medication: _______________________________________________________________________
Any Additional Medical Information: __________________________________________________

In case of emergency, I authorize emergency treatment to be administered if I cannot be contacted.

Signature: _____________________________ Date: _____________
                                  TENTATIVE FIELD TRIP PROGRAM

                                            May 21, 2012

                          Time                               What to do?
                          7:30am                                 Be at school
                          9:30am                              Departure to UCA
                          10:15am                          Arrival UCA and Check-in
                       10:30-12:30pm                  Admissions Counselor and Campus
                                                             Tour(Walking Tour)
                          12:45pm                   Departure to LISA Academy High School
                          1:30pm                    Arrival LISA Academy High School and



Mr.Yasin: 501-442-0587 or


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