Trip Destination
Date of Trip
Purpose / Description of Trip
Departure Time
Expected Return Time
Mode of Transportation Chartered bus Parent vehicles Public transit Walking Other
Supervising Teacher(s)
Cost (if applicable)
Student's Full Name
Grade
Alberta Health Care Number
Full Name
Relationship to Student
Phone Number (Home)
Phone Number (Cell)
Email Address
Emergency Contact (if different)
Emergency Contact Phone
Does your child have any medical conditions?
Yes No
Does your child carry an EpiPen or inhaler?
Requires medication during trip?
Medication Name and Dosage
Administered by
Student (self) Supervising staff
Dietary Restrictions / Special Needs
By signing below, I agree and give permission for my child to participate in this trip and understand all responsibilities and risks involved.
Consent Decision
YES — I give permission NO — I do NOT give permission
Would you like to volunteer?
PIC Status
Yes No In Progress
Trip Fee
Payment Method
Cash Cheque E-Transfer Fee Waiver
Amount Paid
Date Paid
Received By
Submit Form
inquiry@nwislamicschool.com
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