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8th Grade Georgia Trip Permission Form

We are proud to offer the Autrey Mill eighth grade students an exciting and educational trip to Savannah, GA. The Georgia Trip will take place on Thursday, October 28, 2021 through Friday, October 29, 2021 and will include visits to First African Baptist Church, Fort Jackson, River Street, Forsyth Park, and historic tours of Savannah. 

The trip is being sponsored by Autrey Mill Middle School’s 8th Grade Social Studies Department. We will be leaving before school on October 28th and returning in the evening of October 29th.  We will have forty staff chaperones with an expected ratio of 12 students for every adult. 

We will travel to Savannah in luxury motor coaches.  While in Savannah, 8th Grade Georgia Studies comes to life as students will visit places of historic interest.  We also offer students some social time with shopping on River Street Park and an evening riverboat cruise and dance.

The cost of the trip is $240.  We feel all students will benefit from this activity; however, attendance is not required and in no way affects a student’s instruction or grade. We do reserve the right to cancel this field trip if sufficient money is not available to cover all costs. Any student who receives a suspension (ISS or OSS) or multiple disciplinary referrals prior to the trip will be ineligible to attend the trip (this is at the discretion of the administration).

All payments and permission forms are due FRIDAY, SEPTEMBER 24, 2021.   

 

Permission Form or Opt Out Form

Both parent and student need to sign the Permission or the Opt Out form. Please use student’s given name.  These forms are also found on the school website (www.ammslions.org) under quick links Georgia Trip.

All students must have medical insurance coverage to attend the trip. When completing the permission form, have your student’s medical insurance information handy. If your student does not have medical insurance, TW LORD is a low cost option (770-427-2461).  More information is available here: https://twlord.net/APPLICATION-FOR-ENROLLMENT/

Payment 

Pay online at https://www.jimmulvihilltours.com/online-payments. If you have extenuating circumstances that prevent you from making an online payment, such as no debit or credit card, please contact the front office.

Medication

All medications needed for trip must be in the clinic prior to the trip. The forms are posted on the school website under Clinic.  Please contact the AMMS clinic with questions regarding medication.

 

Payment and completed forms must be received in order to participate in roommate selection on Friday, October 1, 2021.  Students who provide payment and/or insurance information past this deadline date will be placed in rooms based on availability.

 

Please contact me at ericksona@fultonschools.org if you have any questions or concerns. We look forward to providing a memorable trip for the 8th grade students.

Anita Erickson

8th grade Assistant Principal

First Student's Name

First Name*

Last Name*
First Student's Date of Birth*
I certify that I am 18 years of age or older
First Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

First Student's Signature*
Second Student's Name

First Name*

Last Name*
Second Student's Date of Birth*
Second Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Second Student's Signature*
Third Student's Name

First Name*

Last Name*
Third Student's Date of Birth*
Third Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Third Student's Signature*
Fourth Student's Name

First Name*

Last Name*
Fourth Student's Date of Birth*
Fourth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Fourth Student's Signature*
Fifth Student's Name

First Name*

Last Name*
Fifth Student's Date of Birth*
Fifth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Fifth Student's Signature*
Sixth Student's Name

First Name*

Last Name*
Sixth Student's Date of Birth*
Sixth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Sixth Student's Signature*
Seventh Student's Name

First Name*

Last Name*
Seventh Student's Date of Birth*
Seventh Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Seventh Student's Signature*
Eighth Student's Name

First Name*

Last Name*
Eighth Student's Date of Birth*
Eighth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Eighth Student's Signature*
Ninth Student's Name

First Name*

Last Name*
Ninth Student's Date of Birth*
Ninth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Ninth Student's Signature*
Tenth Student's Name

First Name*

Last Name*
Tenth Student's Date of Birth*
Tenth Student's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Tenth Student's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
I give permission for my child to accompany his/her class on the Georgia Trip and will make payment by September 24, 2021.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Student Number: *

Student Medical Insurance Information


Medical Insurance Provider: *

Insurance Group ID Number: *

Medical Insurance Member ID Number: *

Students Medication (select one):

Dietary Restrictions (select one):


If Other Dietary Restrictions, please list:
I would like to donate to the field trip scholarship fund for student in need of financial assistance. If so, please give amount in text box and include that amount in your students payment.*
No
Yes

Donation Amount

Student Behavior Agreement 

I will abide by all school rules and policies while on this field trip.  Although I am away from home, I understand that while in Savannah I will be representing my school, community, and parents. Furthermore, I understand that if I disobey school rules I may be subject to appropriate consequences as outlined in the Fulton County Code of Conduct which may also include being sent home early from the field trip.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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