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:______________________________