North Carolina School of Science & Mathematics

SCHOOL SANCTIONED ACTIVITIES FORM

Separate form to be completed for each Student on the trip

Off-Campus Trip (Outside Local Area or Overnight) --  Competitions, Field Trips, and Events at a distance.

Sponsoring Staff Member(s) _______Diane Futrelle, John Kolena__________________________

Additional Chaperon(s) __________________________________________________________

Activity ____Spain Trip: Andalusian Fiesta____________________________________________

(Provide a more detailed daily itinerary on reverse as appropriate)

Location ____________________________________ Contact Telephone __________________

Departure Day: Thursday                            Date _March 29, 2007_______ Time _______________

Return Day: Saturday       _________  Date _April 7, 2007____________ Time _______________

NCSSM Vehicles Requested:

____ 6 passenger mini-van ____ 10 passenger van ____ 14 passenger mini-bus

____ 24 passenger bus ____ 36 passenger bus ____ None required

Driver(s) ______________________________________________________________________

Student Name _______________________________ Campus Address ____________________

Parent Name ________________________________ Parent Telephone ___________________

Parental Permission/Waiver:

I (we), the parent/legal guardian of ______________________________ hereby grant permission for my (our) son/daughter to participate in the trip described above.

I (we), further agree to hold and save NCSSM, all current and former officers, agents and employees of NCSSM, and all their successors, in both their official and individual capacities; harmless from all claims and liabilities, including costs and expenses, on account of any liability, including but not limited to death, personal injury, or property damage, arising directly or indirectly from the trip described above.

___________________________________________ __________________________

Signature of Parent/Legal Guardian Date

Staff Sponsor Verification:

___ Telephone ___ In-Person Confirmation Date _______________ Time __________

Staff Sponsor Signature ______________________________________ Date _______________