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49 views

Permission Slip

Uploaded by

api-241329125
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Parental or Guardian Permission and Medical Release

I give permission for my child/youth to participate in the activity


listed above and authorize the adult leaders supervising this activity
to administer emergency treatment to the above-named participant
for any accident or illness and to act in my stead in approving nec-
essary medical care. This authorization shall cover this activity and
travel to and from this activity.
Activity
Ward Stake
Date of birth
City
Date
Home telephone number
Business telephone number
State/Province
Participant
Participants parent or guardian
Address
Medical Information
Does the participant have any of the following:
Special diet Allergies M edication Chronic/Recurring illness Surgery or a serious illness in the past year Physical conditions that limit activity
If yes, explain below. Use back if more space is needed.
Parent or guardians signature
6/98. Printed in the USA. 33810
Date
Parental or Guardian Permission and Medical Release
I give permission for my child/youth to participate in the activity
listed above and authorize the adult leaders supervising this activity
to administer emergency treatment to the above-named participant
for any accident or illness and to act in my stead in approving nec-
essary medical care. This authorization shall cover this activity and
travel to and from this activity.
Activity
Ward Stake
Date of birth
City
Date
Home telephone number
Business telephone number
State/Province
Participant
Participants parent or guardian
Address
Medical Information
Does the participant have any of the following:
Special diet Allergies M edication Chronic/Recurring illness Surgery or a serious illness in the past year Physical conditions that limit activity
If yes, explain below. Use back if more space is needed.
Parent or guardians signature
6/98. Printed in the USA. 33810
Date

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