Parent/Guardian Permission Form
Student must have permission form on file to participate in the college visit.
College Visit | Wednesday, April 5th | Appalachian State University & Winston-Salem State University
8:15 a.m. – Check in @ Crosby Scholars office, 2701 University Parkway, Winston-Salem, NC 27105
Please arrive by 8:15 a.m. The bus will depart promptly with or without you.
10:30 a.m. – Bus arrives at Appalachian State University
12:30 p.m. – Lunch provided by Crosby Scholars Program
3:00 p.m. – Bus arrives at Winston-Salem State University
4:30 p.m. – Pick up @ Crosby Scholars office, 2701 University Parkway, Winston-Salem, NC 27105
Please have a ride arranged for 4:30 p.m. when we return to the Crosby Scholars office.
I give my student, _____________________________________ (STUDENT NAME), a student at _________________________________________
(HIGH SCHOOL NAME), permission to participate in the Crosby Scholars College Visits on the date marked above. I understand that I am responsible for providing transportation to and from the Crosby Scholars office. Further, I understand that it is my responsibility to arrange transportation for my student to be picked-up at the designated time, thereby releasing the Crosby Scholars staff of the responsibility of supervising my student after the conclusion of the program (4:30 pm). In the case of an emergency, I authorize the Crosby Scholars staff to seek the appropriate medical treatment for my child. I hereby release the Crosby Scholars Community Partnership, Goodwill Industries, Appalachian State University, Winston-Salem State University, and Ben’s Discount Bus Tours of any liability in the event of accident or emergency.
In case of emergency, please contact (name) __________________________________ at (phone #) ______________________________.
I have listed my child’s special medical conditions below: ________________________________________________________________________ ________________________________________________________________________
Parent Signature: ______________________________
Date: _____________________
Please physically or digitally sign above- a typed name will not qualify as a signature.
Email address: