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Emerald Elementary

Mr. Gary Lindstrom 4th grade teacher


906-341-4332 ext.565

PERMISSION FORM
2017 Au Sable Light Station Hike
Permission and Acknowledgment

I, ___________________________, hereby allow my child ____________________________


to participate in the 2017 hike to the Au Sable Light Station on September 30th. I acknowledge that
the trip is part of the educational process and provides a learning experience for my child. The hike
is 4 miles trip and is part of the Pictured Rocks trail network. It is not paved or handicapped
accessible and can be very strenuous.

I also give my permission to the field trip chaperones to pursue emergency medical treatment,
including x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and

hospital care, to be rendered to our/my child ________________________ on advice of any


physician or surgeon licensed to practice in the jurisdiction in which our/my child is located.

List any allergies here: _____________________________________________________


and have your student bring any medication required on the field trip.

Signed:

_______________ ________________________________
Date Parent/Guardian Signature

Because of the nature of the area, volunteers will be needed and appreciated.

_________ I am willing to chaperone

Phone number __________________________

Student Code of Conduct

It is a privilege for you as a student to participate in this hike. Because the field trip is part of the
educational process and experience, you will be expected to adhere to the Student Conduct
standards spelled out in the Student Handbook. Violation of the Student Conduct guideline may
result in removal from the field trip and /or further discipline upon return from the field trip.

Student Signature: ___________________________________ Date: ______________

Parent Signature: ___________________________________ Date: ______________