St. Ephrem School

5340 Hulmeville Road, Bensalem, PA 19020

FIELD TRIP PERMISSION FORM

We (I) as parent(s) or legal guardian(s) of  _______________________________________  give permission for our (my) child to participate in:

Field Trip _____________________________________Date  ___________________

This permission includes all related programs or events associated with the field trip.  In consideration for our (my) child’s participation, we (I) and our (my) child agree and understand that we assume the risks inherent in the field trip, and with full knowledge of the risks, we (I) agree to release and hold harmless St. Ephrem School, St. Ephrem Parish, and the Archdiocese of Philadelphia and their employees  and representatives, from claims arising or related to our (my) child’s participation. 

Our (My) child understands and agrees to abide by all rules and regulations established by the school pertaining to such field trip.

We (I) consent to and give permission for emergency medical care for our (my) child that may be needed as a result of our (my) child’s participation:

Insurance Information (optional)

Insurer _____________________________               Group # _____________________

                                                                                    ID #  ________________________

Student’s Signature:  ________________________________Date  _________________

Parent/Guardian Signature:  __________________________ Date  _________________

Parent/Guardian Signature:  __________________________ Date  _________________

N.B.     Each student must return the signed permission form before being permitted to participate on the field trip.

            Both parents/guardians are required to sign the permission form unless court documentation is provided establishing sole custody of the student.  If a parent/guardian is unable to sign for a valid reason,  that reason must be noted on this form.