Parent Notification/Consent Form
Name ___________________________________________ Class 9th Grade
School (list additional trip sponsors when applicable) Queens Collegiate
Trip Date: _Friday, January 30, 2009
Trip Coordinator: Mrs. Dubei & Mr. McMahon
Destination: 100 Years of American Humor, Lincoln Center, New York, NY
Cost: $5 but subsidy is available.
My child will:
____Bring a lunch or ____ bring money for lunch
Children may bring cell phones and other electronics on this trip.
Departure Site: Queens Collegiate Departure Time: 9:00am 1/30/09
Return Site: Queens Collegiate Return Time: 1:30pm 1/30/09
Mode of Transportation: School bus
Purpose of Trip: See a play, learn about drama, theater and the short story. Experience Lincoln Center.
Specific Clothing/Equipment required for this Trip: None
This trip will include the following physical and sports activities: Walking
I, the parent/guardian of the student named above, hereby give my permission for my child to take part in the school trip described above.
a) I understand that there are potential risks associated with the above-listed activities and I consent to my child’s participation in all activities except for the following:
b) Please indicate below any permanent or temporary medical or other condition including special dietary and medication needs, or the need for visual or auditory aids, which should be known about your child: ________________________________________________________________________________________________________________________________________________________________________________________________________
c) I understand that as a parent, if I believe it is necessary to limit my child’s activity to a great extent, then the school may not be able to accommodate my child on this trip and that I and my child will be informed of this decision as soon as possible upon the receipt by the school of this completed consent form.
d) I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
e) I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child shall be accompanied by staff member(s) while traveling from the departure site to the destination site, and from the destination site to the return site.
f) I understand that it is within the school’s discretion to change travel, accommodations and other arrangements as it deems necessary. I will be informed of such changes as soon as practicable.
g) I understand that the school in arranging for my child’s travel and accommodation selected commercial airlines, trains, restaurants, hotels and other services whose performance and service cannot be controlled by the school. Consequently the school is not responsible for the actions of these commercial entities, including but not limited to lost luggage, unsatisfactory quarters, and refunds.
h) I understand that my child is expected to behave responsibly and to follow the school’s discipline code and policies.
i) I agree and understand that I am responsible for the actions of my child, and I release the school from all claims and liabilities that arise in connection with the trip, except if due to the negligence of school officials.
j) I understand that students who violate the school’s discipline code may be excluded by the school from participating in a trip. Additionally, I understand that if a serious or reported violation occurs while on the trip, it is within the school’s discretion to send my child home from the program, of which I will be informed. I understand if my child is sent home early, I am responsible for all costs associated with such early departure and forfeit any monies paid that are not refunded to the school.
k) In an emergency I can be reached at: Day phone: (__) _______ Evening Phone: (__) ________
Additional Contact: Name ______________Day phone: (__) _______ Evening Phone: (__) ________
l) I give my permission for my child to participate in this school trip.
(Signature of Parent/Guardian) (Date)
(to be signed by Middle School and High School students)
I have read this form and I understand that I am to act on this trip in the same responsible manner in which I am expected to conduct myself in school.
(Signature of Student) (Date)