JOOI - Permission Slip

Junior Optimist Club

Permission Slip

My youth,_________________________________________, has my permission to attend the_______________________

The cost will be_________________________

The mode of transportation will be by:__________________________
We will leave__________________________at_______________am/pm_________and return by___________________________am/pm.

I will take full responsibility and liability for my youth on this trip. The chaperone(s),
_________________________and______________________________
have_________, or, do not have________________, my permission to take the necessary action in case of illness while on this trip.

My emergency numbers are:
(Home)_______________(Cell)_______________________
(Pager)______________________
(Alternate Number)______________________________

My address is:_________________________________
___________________________________

In case of emergency, please contact: 
Name_____________________________
Address:____________________________________________________________
Phone # ____________________________________________________________

My child has the following allergies:________________________________

My child is on the following medication(s):____________________________

Parent/Guardian Name:______________________________________________

Parent/Guardian Signature:____________________________________________

Permission Slip (or form) must be returned by _______________________

Junior Optimist Advisor:_____________________________

Telephone:_____________________________Cell:______________________________