Type and location of trip: __________________________________________________

Date, Time and place of departure: ___________________________________________

Time and place of return: __________________________________________________

Mode of transportation: ___________________________________________________

Cost: ___________ Due by: ______________________________________________

What to bring (Equipment and clothing): _____________________________________

Return permission form below by: ___________________________________________

In case of emergency during the trip, the leader will notify the person below who will notify parents:

Name: ____________________________________ Phone: ______________________

I give full permission for my daughter, ________________________________________

to go to the following field trip: _____________________________________________

_______I agree that she is in good physical condition and has not had any serious illness or operation since the health form was filled out. If any medical insurance information or Doctor have changed, please list here:_________________________________________

________________________________________________________________________

_______Please let us know if there is anything that might limit her participation in this activity on back of form.

Number you can be reached at during the period of time the girls will be in our care: ____________________________________

Parent’s Signature: ____________________________________ Date: _____________