Transportation Release

MOSES LAKE SCHOOL DISTRICT
MOSES LAKE, WASHINGTON
766-2666
FAX 766-2682


EXTENDED TRIP – PARENT REQUEST FOR DEPARTURE FROM GROUP

As parents, should you request to allow your son/daughter to(a) not return with the group, or (b) depart from the scheduled itinerary, you must complete the following form and return it signed to the administrator at least on week prior to the group’s departure from school.

I, _________________________________, request that my son/daughter,
(Parent Name)
__________________________________, be allowed to depart from the itinerary as
(Student Name)

planned for the __________________________________.
(Group)

Please describe:

Reason for departure: ______________________________________
Date of departure: _________________________________________
Emergency Phone:  ________________________________________
Name and age of adult supervisor that your son/daughter will be with if other than

Departure from the group has been acknowledged by the supervisor, teacher, coach or activity advisor.  PLEASE MAKE SURE COACH/ADVISOR SEES PARENT BEFORE YOU LEAVE ACTIVITY.
__________________________________
Supervisor’s Signature (Coach)

As parent or guardian of the above named student, I promise to hold School District #161 harmless from any liabilities it may incur from the above named departure of the extended field trip, except as may arise because of negligence on the part of School District #161 or its employees.

Parent Signature of Student __________________________________   Date _________

Driver Signature (Non Parent) ________________________________  Date _________

Administrator Signature _____________________________________  Date _________