Chancellor’s Regulation A-670 Parent Notification/Consent Form Neighborhood Trip Form
Student’s name ________________________________________________
For: Students on a first come, first served basis as there are a limited number of seats for this trip
School: Queens Collegiate
Trip Date: Friday, January 29, 2010
Destination: Hunter Mountain, New York
Trip Coordinator: Robert McMahon, Assistant Principal
Arrival for Departure Site: Queens Collegiate in front of the building
Arrival Time: 5:30am Departure Site: Queens Collegiate
Departure Time: Promptly at 6:00am
Return Site: Queens Collegiate
Return Time: 5:00-6:00pm pending on traffic
Cost: $100 plus suggested cash on hand of $20-$30 for lunch, snacks, locker rental * The $100 is due at the same time as this permission form and may be cash or check made out to Queens Collegiate. Unless the trip is cancelled by Queens Collegiate, the $100 is non-refundable. If your child misses the bus on the day of trip, they will not be issued a refund. *
All monies and permission slips are to be turned into Mr. Sklar during 5th period in the main office before the deadline of Friday, December 18, 2009.
Mode of Transportation: Coach Bus (or chauffered van if enrollment is not sufficient for a coach bus)
Purpose of Trip: This is a physical education initiative conducted by Queens Collegiate at the end of NYS Regents week on a day when no exams are being conducted. S
pecific Clothing/Equipment required for this trip: Appropriate clothing for the weather. Please check the weather for area code 12442 before the trip. Rather than heavy clothing, wearing layers is strongly suggested.
This trip will include the following physical and sports activities: A 90-minute group ski/snowboarding lesson by a Hunter Mountain instructor, a lower mountain lift ticket with usage of ski ropes and ski lifts for skiing/snowboarding, plus ski/snowboard with boot and pole rental.
________________________________________________ , 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 understand that my child is expected to behave responsibly and to follow the school’s discipline code and policies. f) 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. g) I understand that 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) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site. h) I understand that alcoholic beverages and/or illegal drugs are prohibited and have discussed this prohibition with my child. I understand that if my child is found in possession of these substances, he/she will be subject to school disciplinary procedures and possible criminal prosecution. i) I understand that students who violate the school’s discipline code may be excluded in the future by the school from participating in a trip. j) In an emergency I can be reached at: Day: (__) __________________ Evening: (__) _______________ Additional Contact: Name ___________________ Day:(___)____________Evening: (__) ______________ k) I give my permission for my child to participate in this school trip. l) I give permission for my child to be dismissed on their own upon our return to Queens, as per their discretion, unless noted otherwise here _______________________________________________________. _____________________________________________________ _________________
(Signature of Parent/Guardian) (Date)
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)