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3rd & 4th grade permission slip

Location: Quiet Valley Living Historial Farm, Stroudsburg, PA

Date: November 4, 2024

Departure & Return times: Leaving school at 8:20 and returning to CCA at 2:15

Cost: $10

Lunch: Bring a bagged lunch

Dress Code: Girls are allowed to wear jeans or casual pants, a t-shirt and sneakers. Boys are allowed to wear jeans, or athletic style pants, a t-shirt and sneakers. Students need to wear a jacket.

Transportation: Bus

Chaperones: The trip will be chaperoned by Mrs. Ashley & Mrs. Kambic

Emergency Phone numbers: Mrs. Ashley 570-647-7916 and Mrs. Kambic 570-228-9372

Student First & Last Name*

Answer Required

Grade*

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Parent/Guardian First & Last Name*

Answer Required

Parent/Guardian Phone Number*

Number Required

Emergency Contact Name*

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Emergency Contact Phone Number*

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Family physician*

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Family physician phone number*

Number Required

Special medical conditions:

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Credit/Debit Card Payment for student

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$10.00

Payment by cash or check

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Student ($10)

I give my consent as the parent or guardian of the above named student to participate in this event. In doing so, I agree to the following:

In case of a medical emergency, I grant the chaperones the right to authorize medical care, if none of the persons named above can be reached.
I agree to pay the expenses of returning my child home before the end of the event if he or she does not adhere to the established standards of conduct.
The school is not responsible for damage or loss of property personally owned by my child.

Parent/Guardian Signature*

Signature Required

Confirmation Email

Confirmation Email *

Email Required