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SUNY Delhi Trip Form

School: The Urban Assembly Maker Academy Trip Date: Wednesday, October 4th

Trip Coordinator: Amanda Bercovici & Ms. Davila

Trip Site: SUNY Delhi

Departure Site: UA Maker

Departure Time: 6:30am

Return Site: UA Maker, Evening

Mode of Transportation: Charter Bus

Student Last Name*

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Student First Name*

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Parent/Guardian First Name*

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Parent/Guardian Last Name*

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Parent/Guardian Email Address*

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Parent/Guardian Phone Number*

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Emergency Contact Name*

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Emergency Contact Email*

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Emergency Contact Phone Number*

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Important medical information that we should know

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I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child. I understand that my child is expected to behave responsibly and to follow the school’s discipline code and policies. I agree and understand that I am responsible for the actions of my child. I release the school from all claims and liability that arise in connection with the trip, except if due to the negligence of school officials. I understand that I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child shall be accompanied by staff member(s) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site. I understand that alcoholic beverages and/or illegal drugs are prohibited and have discussed this prohibition with my child. I understand that if my child is found in possession of these substances, he/she will be subject to school disciplinary procedures and possible criminal prosecution. I understand that students who violate the school's discipline code may be excluded in the future by the school from participating in a trip. I give my permission for my child to participate in this school trip.

Signature*

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Confirmation Email

Confirmation Email *

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