PERMISSION SLIP

 

Child's name: ___

 

Activities: ___

 

Places: ___

 

Dates: ___

 

Leaving from: ___

 

Time of departure: ___

 

Returning to: ___

 

Date & time of return:   __/__/___,   __:__am/pm

 

Bring: ___

 

Fee: ___

 

Dress: ___

 

Other materials: ___

 

Contact information:

 

Contact Group Leader: ___

 

Phone: ___

 

Cell phone: ___

 

Contact 'Home Organization': ___

 

Phone: ___

 

Cell phone: ___

 

Contact 'Site Organization': ___

 

Phone: ___

 

Cell phone: ___

 

Parent/Legal Guardian; cut at line and retain the above portion. Complete and return the portion below to leader/adult in charge by:

 

Date: __/__/____

 

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PERMISSION SLIP

  

Child's Name: ___

 

Age: ___

 

Activities: ___

 

Dates: ___

 

My child has my permission to attend the activities listed above.

I give my permission to have my child treated by a licensed physician if necessary.

I also agree to be financially responsible for all expenses associated with providing medical care for my child.

 

TRANSPORTATION RELEASE: I understand that group leaders must obtain the written consent of parent/guardian for every child wishing to participate in an activity or outing that is held at a different place and time from the regularly scheduled group meeting. If transportation is not provided by or arranged by 'Organization', I accept responsibility for the transportation of my child to and from any activity and recognize that transportation to and from events is not the responsibility of 'Organization'. It is my expressed intention to hold 'Organization' harmless for any and all injuries, death or damages arising from, or in any way related to any such transportation.

 

Also if you have made arrangements to have a person other than yourself provide transportation to and/or from this event, please indicate;

 

Name: ___

 

Phone number: ___

 

Address: ___

 

Relation to participant: ___

 

Additional Remarks ie; (Description): ___

 

 

Check one:

 

I (give) ___

 

I (refuse) ___

 

permission for my child to participate in boating, swimming, horseback riding, or other strenuous activities.

If no exceptions, participation is allowed in all activities at this outing.

 

EXCEPTIONS:

My child may not be released to:

 

Event 1: ___

 

Event 2: ___

 

Event 3: ___

 

Or, 

Please indicate any special accomodations needed because of;

 

Allergies. ___

 

Diet. ___

 

Health conditions. ___

 

Mental conditions. ___

 

Physical conditions. ___

 

Sleeping arrangements. ___

 

 

 

If unable to reach me in case of an emergency or change in plans, please contact one of the following.

I will make arrangements with these people prior to the event.

1-

Name: ___

 

Day: ___

 

Evn: ___

 

Relationship: ___

 

 

2-

Name: ___

 

Day: ___

 

Evn: ___

 

Relationship: ___

 

I have provided medication(s) for my child to take with the supervision of the Group Leader.

Yes: ___

No: ___

 

Complete this list of all medications with clear storage needs and clear dosage instructions.

 

Medication 1: ___

 

Dosage: ___

 

How Often: ___

 

 

Medication 2: ___

 

Dosage: ___

 

How Often: ___

 

 

Medication 3: ___

 

Dosage: ___

 

How Often: ___

 

 

Medications my child can have: ___

 

Medications my child cannot have: ___

 

Allergies: ___

 

Diseases exposed to in last 30-days: ___

 

Date of last tetanus shot __/__/____.

 

You may also include the name of the hospital or doctor of your choice and their phone numbers for use at local events.

However, if our event is not local, emergency treatment will be obtained at a location deemed most appropriate.

 

 

Signature of Parent/Legal Guardian:

 

 

 

Print Name of Parent/Legal Guardian:

 

 

 

Address:

 

Phone:

 

Pager:

 

Cell Phone:

 

Date: __/__/____

 

 

By signing this form, I declare that I am the legal parent/guardian of the child listed above and authorized to grant such permission.

This form may also be used for other than a minor child. If this is the case, please note here that the participant is not a minor, is your dependant and that you are the legal guardian.

 

Participant is not a minor; ___

 

For confirmation, contact: