Field Trip - Park/Lunch - St. Mark's Lutheran Church and School

St. Mark’s Lutheran School

Sponsoring Class: PK
Destination of Field Trip: Culver's (400 Meramec Blvd, Eureka, MO 63025) Shaw Park (Surrounding Streets: Meramec Blvd, Sierra Village Dr, and Shaw Dr, Eureka, MO 63025)
Date: Wednesday, May 8
Start time: 9:30 a.m. Return time: 12:00 p.m.
Cost: $7.00 or $7.50 depending on meal selection per student
Lunch: At Culver's
Drivers Needed: No, this is a walking field trip.
Parental Attendance: Yes, space is limited to 3 parents. Spots will be filled on a first come basis.
Dress Code: Connected in Christ Shirts, casual bottoms, tennis shoes or walking shoes
Details: Ms. Debbie, Ms. Amy, Ms. Sharon and Mrs. Brevard will be supervising. We will spend the morning at the park then eat lunch.

Student Information

1. Student Name(Required)

First Last

Grade

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Mom's Cell Phone

Dad's Cell Phone

Parent Preferred Email

Additional Emergency Name

First Last

Additional Emergency Phone

Background Check

Will you (the parent) be attending this field trip?(Required)

Yes

Permission to Obtain a Background Check
(This form authorizes the church/school to obtain background information and must be completed by the applicant. The church/school must keep this completed form on file for at least two years after requesting a background check.)
I, the undersigned applicant (also known as “consumer”), authorize St. Mark’s Lutheran Church and School through its independent contractor, Protect My Ministry, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and the state sex offender records.
I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to St. Mark’s Lutheran Church and School, if such is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.

Signature

Hidden

Date

Identifying Information for Background Information Agency (also known as “Consumer Reporting Agency”)

Name

First Middle Last

Other Names Used (alias, maiden, nickname):

First Middle Last

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Former Address

(Past 7 years)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Former Address

(Past 7 years)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number

Hidden

Phone

Driver's License Number

State of Issuance

Birthdate

Gender

Male

Female

Hidden

Transportation

Hidden

Transportation provided by(Required)

First Last

Hidden

I can provide transportation.

Yes

Hidden

Number of seatbelts available for passengers.

Hidden

Driver's Licence

Please upload a photo of your drivers license.

Max. file size: 512 MB.

Hidden

Insurance Card

Please upload a photo of your vehicle insurance card.

Max. file size: 512 MB.

Hidden

Passenger 1

First Last

Hidden

Passenger 2

First Last

Hidden

Passenger 3

First Last

Hidden

Passenger 4

First Last

Hidden

Passenger 5

First Last

Hidden

Passenger 6

First Last

According to the Missouri State Highway Patrol, children less than 4 years old are required to use a child passenger restraint system. Children less than 40 pounds, regardless of age, must be secured in a car seat. Children ages 4 to 8 years old that weigh at least 40 pounds but less than 80 pounds, and are less than 4’9” tall, must be secured in a booster seat. Children ages 8 through 15 are required to wear seat belts. It is the driver’s responsibility to ensure passengers under the age of 15 are buckled up safely. The driver can be pulled over and ticketed for noncompliance of these laws. It is the parent’s responsibility to provide a car seat or booster seat for their child if they are not big enough or old enough to be secured in a seat belt. If a safety seat is not provided, the child will not be able to go on the field trip. We want all of our children to be safe when going on field trips. Consent Information: We, the undersigned parents/guardians of the above named participant, grant permission for the participant to participate in the aforementioned field trip. We, furthermore, authorize transportation as described above for the participant. We have been advised of the nature and extent of the activities that may take place and represent to you that the participant is physically and mentally able to participate in those activities. We further understand that the activity does present the risk of injury, or even death, to the participant and we have advised the participant of these possibilities. We represent to you that we and the participant assume risk of any such injury or death, and hold you, your agents, employees, and representatives harmless from any liability for injury or death to the participant while engaged in this activity which is caused or contributed to by the conduct of the participant. We further agree to indemnify and defend you against any claim or liability asserted against you for any such injury or death to the participant. We also hold you, your agents, employees, and representatives harmless from all liability to any other person or entity arising as a result of the conduct of the participant in this activity, and agree to defend and indemnify your agents, employees, and representatives against any claim or liability arising as a result of such conduct. If we are not personally present at these activities in which the participant is to participate, so as to be consulted in the case of necessity, you are authorized on our behalf to arrange for such medical and hospital treatment as you may deem advisable for the health and well being of the participant.

Parent Signature(Required)

Date(Required)

THIS FORM MUST BE PROPERLY SIGNED & RETURNED BEFORE PERMISSION TO PARTICIPATE IN THIS FIELD TRIP MAY BE GRANTED. *72 HOURS PRIOR TO EVENT: Drivers must provide a copy of their driver’s license, proof of insurance, and a background check request to the office. All adults attending the event must have a background check on file and have watched the “Protect My Ministry” video.