"Permission Form for Student Travel"

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JEFFERSON COUNTY
BOARD OF EDUCATION
PERMISSION FOR STUDENT TRAVEL
(TO BE COMPLETED BY TEACHER/SPONSOR/COACH)
SCHOOL:
___________________________________________________________________________________
TEACHER/SPONSOR/COACH:
_________________________________________________________________
PROPOSED TRIP:
____________________________________________________________________________
(Destination/Event)
DATE OF TRIP:
__________________________
TIME LEAVING SCHOOL:
TIME RETURNING TO SCHOOL:
____________________
__________________
MODE OF TRANSPORTATION:
(TEACHER/SPONSOR/COACH TO SELECT ONE OF THE FOLLOWING)
BOARD PROVIDED/ARRANGED:
____________
( ) School Bus
( ) Commercial Carrier
( ) Walk
PARENTAL RESPONSIBILITY
____________
(
It is the sole responsibility of each individual parent to provide for or
otherwise arrange for transportation to and from this activity. The Board cannot and will not be responsible for insurance or
safety for parent-provided or arranged transportation. Parents should make arrangements to ensure the safety of his or her
own child.)
has my permission to participate in the above school sponsored trip
_________________________________________
or off-campus extracurricular activity. I understand that it is my responsibility as a parent/guardian to provide the
school with emergency information, including but not limited to: home and work phone numbers, emergency
phone numbers, and necessary medical information.
______________________________________ Parent/Guardian
______________________________________ Date
JEFFERSON COUNTY
BOARD OF EDUCATION
PERMISSION FOR STUDENT TRAVEL
(TO BE COMPLETED BY TEACHER/SPONSOR/COACH)
SCHOOL:
___________________________________________________________________________________
TEACHER/SPONSOR/COACH:
_________________________________________________________________
PROPOSED TRIP:
____________________________________________________________________________
(Destination/Event)
DATE OF TRIP:
__________________________
TIME LEAVING SCHOOL:
TIME RETURNING TO SCHOOL:
____________________
__________________
MODE OF TRANSPORTATION:
(TEACHER/SPONSOR/COACH TO SELECT ONE OF THE FOLLOWING)
BOARD PROVIDED/ARRANGED:
____________
( ) School Bus
( ) Commercial Carrier
( ) Walk
PARENTAL RESPONSIBILITY
____________
(
It is the sole responsibility of each individual parent to provide for or
otherwise arrange for transportation to and from this activity. The Board cannot and will not be responsible for insurance or
safety for parent-provided or arranged transportation. Parents should make arrangements to ensure the safety of his or her
own child.)
has my permission to participate in the above school sponsored trip
_________________________________________
or off-campus extracurricular activity. I understand that it is my responsibility as a parent/guardian to provide the
school with emergency information, including but not limited to: home and work phone numbers, emergency
phone numbers, and necessary medical information.
______________________________________ Parent/Guardian
______________________________________ Date