Christian Brothers College High School Activities Trip Permission Form

							                      Christian Brothers College High School Activities Trip Permission Form

Date of Trip:   February 24, 2010

Destination:    Scottrade Center          TRANSPORATION: School Bus

Moderator(s): Jeff Myer, Scott Brown, Jack Jamieson, Craig Nicoletti

Student Cost: $25 (includes admission to basketball and hockey games, box-dinner, transportation )

To be completed by the Students/Parents/Guardians:

                                         Student/Parent/Guardian Agreement
While participating in this field trip, I will accept responsibility for maintaining good conduct and appearance. I will listen
attentively and will follow my moderator’s and chaperone’s directions at all times. I understand that the school has the
right to terminate my participation in the field trip at any time if my conduct is not appropriate and/or if I fail to follow
my moderator’s or chaperone’s directions.

This is an all-inclusive trip and I/We understand that the student MUST remain with the group and ride the bus to and
from all events. The student may not be released to anyone, other than a parent/guardian, at anytime during the event.
It is the student’s responsibility to ensure that he is on the bus prior to the bus departing. Students SHALL NOT leave an
event with anyone other than the moderators of the event or his parent/guardian, except for at the end of the hockey
game at the Scottrade Center, where students may be dismissed with parental permission (see below).

    I grant my son/guardian permission to be dismissed from the Scottrade Center. Initials _____

CBC shall not be liable for students who leave an event in violation of the above stipulations.

___________ ____                 _                                                                        _____________
    Signature of Student                                   Signature of Parent                                Date

Does the student have allergies or medical conditions or take medication of which the school should be aware? Yes No

If yes, please describe. _________________________________________________________________

Phone Numbers of Emergency Contact(s), Parent and Student’s Cell Phone

Student: __________________________ Parent/Guardian: _____________________________

Parental Authorization
I request that my son, ___________________________________, be allowed to participate in the activities trip listed
above. I understand that this activity will take place away from the school grounds, and I grant my consent to the
method of transportation. I/We release CBC of all liability if my student does not comply with the terms listed above and
if he voluntarily leaves an event with anyone other than a parent/guardian or moderator of the event. I also understand
that this trip exposes my child to unpredictable risks and dangers. If emergency medical treatment is needed, I hereby
empower the school officials to exercise their discretion to transport my child for treatment and to sign any releases
that may be required.

______________________________________________                                      _________________
Signature of Parent/Guardian                                                        Date