SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

APPLICATION TO PARTICIPATE IN AN ACTIVITY

AWAY FROM SCHOOL

Name of student:_____________________________________________________________

Activity:____________________________________________________________________

Date of Activity:_____________________________Sponsor:_________________________

Transportation for this field trip will be by:

School Bus

Public Transportation

Ride in my own vehicle with No passengers

Ride in another vehicle driven by an adult

Other: specify

Your child is requesting the privilege of going on a school-sponsored trip. We MUST have your permission before allowing him/her to go. The school will supervise the trip properly, but it is impossible to assure that no accidents will occur.

The parent understands that participation is purely voluntary and assumes the risk of any injury resulting from or connected to that participation in the trip will not be the responsibility of XYZ Charter. The parent hereby agrees to indemnify, defend and hold harmless XYZ Charter or its trustees, officers, employees and agents against any and all liabilities, losses, damages, claims, actions, or expenses, including reasonable attorney’s fees arising out of any and all claims, demands, causes of action and suits of whatever nature, in law or equity, that arise out of or are connected with, or are based in whole or in part of any conduct, fact, matter, act or mission that relates to or is otherwise connected with transportation to the activity described above.

It is further understood the student is still directly responsible to those teachers sponsoring the trip from the time of departure until arrival at the school. Students must leave and return by the same means of transportation, unless by mutual agreement between the parents and the field trip sponsors. If these agreements are not satisfactory to you, you may choose not to sign this permission form. Please understand that unless you sign this form and return it to the teacher, your child will not be permitted to participate in the field trip.

____________________________________ ___________________________________

Parent Signature and Date Student Signature and Date

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