Field Trip Permission Form – Headwaters Academy

Enrichment Activity – Offsite Permission Form

Activity: Field Trip to Ebenzer Children’s Home

Description: Our 2nd grade class will be delivering buckets of goodies to the Ebenezer Children’s Home

Location: 1006 Byrd Ridge Rd, North Wilkesboro, NC 28659

Date: Feb 13th, 2023

Time: 8:00am – 10:00am

Cost: Free

A few more details:

We will be leaving the school at 8am in a church van driven by Pastor Scott. We will deliver the buckets, snap a picture or two and return back to school. It’s a 45min drive to the home.

Headwaters Permission Form

Child's Name*
First Last
Emergency Contact Name*
First Last
Emergency Contact Phone*
Parent/Legal Guardian's Name*
I give permission for my child to take part in this activity.
First Last
Parent/Legal Guardian Signature*
I am fully aware that my child will be transported to and from this activity and that there will be ample supervision. I have previously completed a Medical/Liability Release Form for my child. By signing this permission slip, I am confirming that the information on his/her Medical/Liability Release Form is current and up to date. I understand in the unlikely event of an accident or emergency that my child will receive adequate care based upon the information given. I assume all risks, hazards and incidentals involved in the conduct of the activity. I do hereby release, indemnify and hold harmless Headwaters Educational Enrichment and South River Baptist Church from any and all loss, injury or other damage arising out of this activity. I understand that the child will be transported to and from the offiste activity and I also understand the inherent risks in any travel, and agree to waive any and all liability on behalf of the referenced organizations for those risks.
Email*
Enter Email Confirm Email
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.