• Club Permission Slip

     I give permission for my child listed below to attend _________________________ .

    (insert name of club)

     

               _________________________________________________       __________________________

                         (Signature of Parent/Guardian)                                                       (Date)

     

    Please CLEARLY Print Information

     

    Name of Child ______________________________________   Date of Birth ____________________

     

    Homeroom Teacher’s Name_________________________________ Grade ____________

               

    Name of Parent/Guardian ______________________________________________________________

     

    Primary Phone Number _______________________   Email _____________________________              Secondary Phone Number _____________________________________________

    Address_____________________________________________________________

    ____________________________________________________________________

    If we are unable to reach the parent/guardian listed at the above phone numbers, whom should we call?

     

    Alternate Contact Name _____________________________________________

     

    Alternate Contact Phone Number ____________________________________

    How will your child get home after club? PLEASE INITIAL ONE.

    _____ Walk

    _____ Car

    (Notes are required from parents for change in transportation.)

     

    NOTE:

    • Children will be dismissed at 4:30 pm and should be promptly picked up or report to the Panther Den and picked up by 6:00 pm.
    • No transportation will be provided at the end of club.

     

    Are there any Medical needs we need to be aware of? (Circle one) No   Yes

    If yes, please complete “Medical Needs” section:

    Medical Needs: (Please indicate if child is allergic to any foods, etc.)

    __________________________________________________________________________________

     

    _____ Please initial if you give your permission for the club sponsor to use your child's photograph for promotional purposes.