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PreK/K5 Permission Slip

Location: Lakeland Orchard

Date: October 2, 2026

Departure & Return times: Leaving school at 9:15 a.m. and arriving back at school at 2:30

Cost: $12.00 (season passes do not apply to field trips)

Lunch: Bring a disposable brown bagged lunch and water bottle

Dress Code: Dress accordingly for the weather; Jeans, t-shirt, and sneakers. Light jacket or sweatshirt if needed.

Transportation: Bus

Chaperones: The trip will be chaperoned by Mrs. Hanna, Mrs. Highhouse, and Mrs. Heminghous

Emergency Phone numbers: Mrs. Hanna (570) 878-4006 and Mrs. Highhouse (570) 498-0470

Student First & Last Name*

Answer required for "Student First & Last Name"

Parent/Guardian First & Last Name*

Answer required for "Parent/Guardian First & Last Name"

Parent/Guardian Phone Number*

Number Required

Emergency Contact Name*

Answer required for "Emergency Contact Name"

Emergency Contact Phone Number*

Number Required

Family physician*

Answer required for "Family physician"

Family physician phone number*

Number Required

Special medical conditions:

Answer required for "Special medical conditions:"

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.

Cost for student (debit or credit)

Answer required for "Cost for student (debit or credit)"

Price: $12.00

I will pay by cash or check made payable to CCA by 10/13

Answer required for "I will pay by cash or check made payable to CCA by 10/13"

$12.00 student

Parent/Guardian Signature*

Signature Required

Note for teacher:

Answer required for "Note for teacher:"

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"