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