Fort Dale Academy

2009 / 2010

SCHOOL ACTIVITY / CLASS FIELD TRIP

PERMISSION FORM

Student Name: __________________________________________________________

Grade/ Teacher: ____________________________

My child has permission to be transported by school transportation to school related activities during the 2009 - 2010 school year. I understand that Fort Dale Academy will not be held responsible for any injury or medical bills associated with injuries or illness. My child may be given emergency medical attention.

Insurance Company: _________________________________________

Policy Number: _____________________________________________

____________________________________ ___________________________

Signature (Parent / Guardian) Date

__________________________________________________________________

Parent / Guardian Name

__________________________________________________________________

Address

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Phone Number

Please list any food or drug allergies:

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