HENNIKER COMMUNITY CENTER FIELD TRIP PERMISSION FORM
Dear Parent/Guardian,
For your child to participate in the Henniker Community Center field trip the bottom of this form must be
completed and returned by August 1, 2015 with payment, which is nonrefundable.
FIELD TRIP INFORMATION
Date of trip: August 12, 2015
Location: Water Country
Departure time: 8:45 am Return time: 4:30 pm
There will be two chaperones on this field trip:
MaryEllen Schule ©491-5270 Shannon Camara ©724-0312.
Transportation will be provided by Goffstown Trucking Services.
The cost of the trip: $35.00 (cash, check payable to “Town of Henniker”)
If your child is to attend a week notification must be given with permission slip below and money for trip
returned by the above date. Thank you.
----------------------------------------------------------------------------------------------------------------------------I give permission for my child _____________________ to attend the Henniker Community Center field trip.
Emergency Contact Name: _________________________________ Contact Number: ________________
Insurance: _______________________________________________ Policy Number: ________________
List any known allergies or medical status of your child we will need in case of emergency:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Upon return of the trip;
( ) my child has permission to walk home/leave without parent/guardian
( ) I will pick up my child
I hereby release indemnify Henniker Community Center and their volunteers from any, all liability arising
from claims of any kind or nature whatsoever from my child’s participation in this field trip.
RELEASE: If emergency treatment is required, and the parents/legal guardian cannot be reached
immediately, your signature provided below empowers the volunteers to exercise their own judgment to
transport the child to a hospital/emergency room.
Parent’s Signature: _____________________________________
Print Name: ____________________________________________
Date: _____________