MARY ELLEN HENDERSON MIDDLE SCHOOL

A Falls Church City Public School

7130 Leesburg Pike
Falls Church, Virginia 22043
(703) 720-5700
Fax: (703) 720-5710

FIELD TRIP RELEASE FORM

Name of Student: _________________________________Homebase Teacher:______________

Permission slip and money are due by: Friday, December 3, 2010

Activity: National Gallery of Art's Ice Skating Rink and Sculpture Garden
Place: National Gallery of Art's Ice Skating Rink
Teachers Responsible: 6th Grade Team
Date: Thursday, January 13, 2011 Mode of Transportation: School Bus
Time Leaving: 9:00 Time Returning: 1:30
Acknowledgment of Liability

My student has my permission to go on this field trip and participate in the activity described above. I
understand that the necessary safety precautions will be taken for the supervision of my student.

The school has my permission, in an emergency when I (or my physician) cannot be contacted, to take my
student to the emergency room of the nearest hospital, and the hospital and its medical staff have my
authorization to provide treatment which a physician deems necessary for the well-being of my student.

I have read this waiver and do not have any questions about the words used or their meaning.

Signature of Parent/Guardian: _____________________________________________

Date: ___________________________ Telephone Number: ______________________

Physician: ________________________Telephone Number: ______________________

My child will need a bagged lunch from the cafeteria for this trip. (Note: this may not apply for all
field trips if students are eating lunch prior to leaving for the field trip.) Lunch number: _________

Check here if you are interested in sponsoring a classmate for this field trip.
Please include your sponsor donation with your child’s field trip payment.

Check here if you are interested in being a chaperone for this trip. Phone number: ______________

Ann M. McCarty Jeanne Seabridge Janae Rittenhouse

Principal Assistant Principal Guidance Coordinator
 MARY ELLEN HENDERSON MIDDLE SCHOOL
A Falls Church City Public School
7130 Leesburg Pike
Falls Church, Virginia 22043
(703) 720-5700
Fax: (703) 720-5710

Please contact the teachers responsible, if you are need of financial assistance for your child for this trip.

Ann M. McCarty Jeanne Seabridge Janae Rittenhouse

Principal Assistant Principal Guidance Coordinator