Field Trip Permission Slip

The following permission slip form is good for all field trips for the 2020/2021 school year.
If Achieve staff will be driving your child you must fill out every field!

* Indicates required field

Student Name *

First

Last

Parent/Guardian Phone Number 1 *

Parent/Guardian Phone Number 2 *

Doctor's Name *

First

Last

Doctor's Phone Number *

Hospital Preferred *

Name of Insurance Company *

Policy Number *

My child takes the following medications: *

By typing my name below, I certify that I am the parent or guardian of the above named student now attending Achieve Learning Center. The above mentioned school has my full permission to allow my child to attend a field trip traveling with an Achieve Staff Member on the streets and public highways. I agree to hold harmless and release from liability Achieve Learning Center or any employee or representative therof, for any action, claim, or damage that may arise as a result of my child's participation. *

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Last

By typing my name below, I agree to the following: In the event my child needs emergency or medical treatment, every attempt will be made to contact us, the parent/guardian. In the event I/we cannot be contacted, I/we give our permission to Achieve Learning Center to secure prompt treatment for my child. *

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Last

Submit

Field Trip Permission Form

Field Trip Permission Slip