Permission form

To parents/guardians:

Your consent is required for child’s participation in this life building experience. If you approve, please accomplish and return the lower half of this form. Please submit the signed form 2 weeks before the conference date.ext

Referring Source:

I wish to be a community partner?: (Y) (N)

YES

NO

If Y, and what capacity?

DAUGHTER INFORMATION

Name of daughter

I allow my daughter to participate in the event.

YES

NO

In case of emergencies, the Program Leaders should call:

Name

Home phone number

Mobile Number

Relationship to child

MEDICAL INFORMATION:

My daughter needs medication during the activity.

YES

NO

If YES, please specify name of medicine and frequency of dosage.

My daughter needs special assistance due to a disability.

YES

NO

My daughter requires special food due to allergies or religious requirements.

YES

NO

If YES, please specify

Our family doctor can be reached at:

Relationship to student

Full Name

Date Signed

Signature