LIBERTY COUNTY
SCHOOL SYSTEM Providing students an education which promotes excellence, good citizenship, and a love of learning
SUPERINTENDENT OF SCHOOLS MEMBERS, BOARD OF EDUCATION Lily H. Baker, Chair • Donita Strickland, Vice Chair
Dr. Franklin D. Perry Verdell Jones • Marcus Scott IV • Carol Guyett • James Johns • Dr. Chante Baker Martin
FIELD TRIP PERMISSION FORM
STUDENT: _______________________________________ DOB: _______________ GRADE: ________
SCHOOL: ______________________________________
PARENT/GUARDIAN: ____________________________________________________________________
PHONE- Work: ________________________ Home: ________________________
ADDRESS: ____________________________________________________________________________
EMERGENCY CONTACT PERSON: __________________________________________________________
PHONE- Work: ________________________ Home: ________________________
I hereby authorize the sponsors for the field trip to have my daughter/son treated at the parent’s/guardian’s expense at the nearest medical
facility, in case of accident or illness.
STUDENT’S DOCTOR: ____________________________________________________________________________
DOCTOR’S PHONE- Office: _______________________________ Home: _________________________________
Please describe completely any medical condition (past or present) being treated which may recur or be a factor in medical treatment (include
allergies, medicine reactions, disease of any kind, physical handicaps, heart or lung problems, seizures, convulsions, blackouts, etc.). If currently
taking medication, state the medication and prescribing physician and phone number:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
NAME OF INSURANCE COMPANY: _________________________________________________________
POLICY NUMBER: _______________________________________
FIELD TRIP DESTINATION: ________________________________________________________________
I understand that all rules for the school are in effect and improper behavior will be dealt with just as if this activity took place at school. I
understand that extreme improper behavior on the part of my child may result in a call that will necessitate me coming to pick up my child from
the field trip.
__________________________________________________________ ______________________________________
Parent/Guardian Signature Date
METHOD OF TRANSPORTATION: ______ School Bus ______ BOE Vehicle
CL-10/6/21
200 Bradwell Street, Hinesville, GA 31313 • 912-876-2161 (Tel) • 912-368-6201 (Fax) • [Link]
AN EQUAL OPPORTUNITY EMPLOYER
