Print out this form and mail it to:
9431 Silver King Court
Fairfax, VA 22031

Make Checks Payable To: The New School of Northern Virginia

The undersigned, an adult of 21 years or older and acting in his/her behalf, or an adult parent or legal guardian acting on behalf of the minor child whose name appears herein, hereby does release The New School of Northern Virginia, Inc.("The New School"), its officers and employees, and any and all, from any liability in connection with school field trips.

It is acknowledged by the adult signing this form that all reasonable safety precautions will be taken by the trip leaders, teachers and parents who are sponsoring these trips, and that upon signing this form, said adult hereby releases The New School, its officers and employees, and any and all, from any and all liability stemming from any injury, accident, or loss on the way to, the way from, or at these activities.

My son, daughter, or ward________________________________, has my permission to participate in school field trips with parents, teachers and students of The New School.

For your child's protection in case of emergency, please complete the following:

Allergies or special problems/needs (please list):

Insurance Co. & policy no.:______________________________________________

Telephone no. where parent or guardian can be reached:_______________________

I have read and understand the above release and permission form. I hereby grant permission for a teacher or parent of The New School to take my child for emergency medical treatment in the event I cannot be reached. I understand that if medical treatment is necessary, I will assume financial responsibility for such emergency treatment.

_________________________________
Signature of parent or guardian

__________________
Date