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5th-6th Grade Field Trip Permission Slip

Location: Promise Land State Park

Date: October 30, 2026

Departure & Return times: Leaving school at 8:45 a.m. and arriving back at school at 2:30 p.m.

Cost: $0

Lunch: Bring a bagged lunch and a water bottle. (no glass)

Dress Code: Jeans/pants; t-shirt/sweatshirt with no writing except for a small logo or CCA spirit wear; comfortable shoes for hiking

Transportation: Bus and school vans

Chaperones: The trip will be chaperoned by Mrs. Brown & Mrs. Hughes

Emergency Phone numbers: Mrs. Brown 570-470-1544 and Mrs. Hughes 570-418-5112

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.

Parent/Guardian Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"