Paid: $______________

Check #______________
Receipt #______________
SCHOOL DISTRICT OF HILLSBOROUGH COUNTY
Application for Participation
in Instructional Field Trips
This form is used for recording student requests to participate in instructional field trips and their parent or guardian’s permission for
them to participate and travel in specified transportation. It must be on file before a student may participate.

Student Request
I, ________________________________________________ am a student in Physics I, Physics IH or AP Physics
Print Student Name Print Name of Class
class at Bloomingdale Senior High school; My Period 2 (Attendance) Teacher is _____________________________.

My home address, including parent/guardian name : _______________________________________________________________

Print Parent/Guardian Name
_____________________________________ __________________________________ ___ _____________________
Print Home Street Address City State Zip
___________________________ _________________________ ___________________________
Home Phone Work Phone Cell Phone

The intent of this voluntary statement is to form an agreement in which I pledge my compliance with the policies in the Hillsborough
Student Handbook and to conduct myself on all field trips in such a manner as to bring honor to my school and myself in return
for the privilege of being included as a participant in field trip activities. I will, to the best of my ability, stay academically eligible by
maintaining at least a 2.0 grade point average.
_______________________________________________________________ ___________________________________
Student’s Signature Date

Parent/Guardian Request
As parent or guardian, I request that ___________________________________________________________ be
Print Student’s Name
included in the field trip to ___Busch Gardens, Tampa,_ that will be conducted on December 3, 2010, from 7:33 A.M. to 2:59 P.M.
Print Name of Trip Destination Month/Day/Year
I understand that transportation will be provided by:

 A private automobile of a parent, teacher, and/or licensed student, none of which is

under the control of the School Board of Hillsborough County.
or
 A Hillsborough District School bus.
or
 A private bus under charter to the Hillsborough County School Board.

_______________________________________________________________ ___________________________________
Signature of Student’s Parent or Guardian Date of Signature

Additional Information
1. Cost of trip is $53.00; NO REFUNDS. Please make checks payable to BLOOMINGDALE HIGH SCHOOL.
2. If a student has a valid pass to enter Busch Gardens, the cost of the bus trip only is $14.00.
3. Money with permission forms are due on or before Friday, November 05, 2010.
4. We need 7 parental chaperones. Chaperones pay nothing except for their own lunch. Contact Mr. Brod at 744-8018
(voice mail extension 427); e-mail jbrod1@tampabay.rr.com or just send a note if you wish to chaperone. Chaperones are accepted
on a first-come, first-served basis.

A copy of this form must be turned into office three days prior to the field trip.

Form SB60531 revised 8/1/96 BG-FTLTR.DOC