Form must be signed and returned to chaperone prior to student participation.

Field Trip Permission Slip

Revised: September, 2005

Student Name: __________________________________ Date:________________ Field Trip Location: Salem Boys and Girls Club Field Trip Date: Wednesday, December 23rd Chaperones: Wendy Olson, Assistant Principal Arrive at club: 3:30p Pick up Time: 6:30p Means of Transportation:

School Van School Bus Students required to provide their own transportation. Parents please initial if you are allowing your

student to drive.

Additional Notes: On Wednesday, December 23rd at 3:30 pm, we will meet at the Salem Boys and Girls Club to help set up for the Boys and Girls Club Holiday party. Students, faculty and staff are welcomed to join us at the club, where we will set up the party, help serve dinner and refreshments, clean up after the party and of course, spend time with the kids at the Club. If you would like to attend, please return the attached permission slip to Mrs Olson by Friday, December 18th at 4pm. The party will last from 3:30 pm until 6:30 pm. Families are asked to drop their sons off at the Boys and Girls Club and pick them up. Transportation will not be provided.

As Parent(s)/Guardian(s) of the above named student we request that our son participate in the above listed field trip. In exchange for the opportunity to participate, Student and Parent(s)/Guardian(s) assume all risks in connection with Student's participation in and travel to and from the Program. Student and Parent(s)/Guardian(s) release SJP, its trustees, officers, agents, employees, chaperones and representatives (individually and in their official capacities) from any and all liability for any personal injury (including death) or damage to personal property (including total loss) in connection with Student's participation in and travel to and from the Program. Student and Parent(s)/Guardian(s) agree to indemnify, defend and hold harmless SJP and/or any of those mentioned above from any and all claims, or causes of action, including liability, losses, damages, judgments or expenses, including, but not limited to attorney's fees, that they or any of them incur or sustain in connection with my participation in and travel to and from the Program. Student understands that this statement covers any and all claims against SJP or any of those mentioned above. Student and Parent(s)/Guardian(s) also understand that this statement binds Student, his family, estate, and/or heirs.

_________________________________________ _____________ Signature of Parent / Guardian Date _________________________________________ Printed Name of Parent / Guardian _________________________________________ _____________ Signature of Student Date