Forms | Alpine Academy of Rockford

Field Trip Information
Location
Aquarium of the Pacific, 100 Aquarium Way, Long Beach, CA 90802

Event Date
09/20/2019

Start Time
8:00am

End Time
2:00pm

Details
Bring a sack lunch

Cost Per Child
$15

Cost Per Chaperone
$20

Due Date
09/15/2019
Student Information
Student First Name*
Student Last Name*
Grade*
Parent Information
Parent / Guardian First Name*
Parent / Guardian Last Name*
Email Address*
Phone Number
Will you be participating as a Chaperone?*
I cannot attend.I cannot drive, but I am available to chaperone.I will chaperone and transport my student and xx amount of students in my care.
Please indicate the number of students you can transport*
Emergency Contact Information
Name
Relationship
Phone Number
Medical Information
Important Medical Information The Supervisor Should Know
Payment Information
*
prevnext( X )
Cost of Trip ($)$15.00

Cost of Chaperone ($)$20.00

Total $0.00
Credit Card Details
First Name Last Name
Credit Card Number
Security Code
Card Expiration
Authorization Signature
By signing below, I acknowledge that I have read, understand, and agree to the Terms and Conditions listed above.Furthermore, I certify that I am the Parent or Legal Guardian of the student named above and that all the information provided is true and correct to the best of my knowledge.
Parent/Guardian Signature*
Long Beach Elementary School
444 W. Ocean BLVD, Suite 800, Long Beach CA 90802 | (323) 375-1120

Privacy Policy | Terms of Service | Powered by Zing Apps
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Field Trip Information

Student Information

Parent Information

Emergency Contact Information

Medical Information

Payment Information

Authorization Signature