Extracurricular Activity
Permission Form
Student Name: __________________________________ Grade: ______ Division: ______
Activity: After
School Walking Program
I,
_________________________________, give permission for my child to
participate in the above activity. My child has the following medical needs:
_____ No Medical
Needs
_____ Inhaler
(type) ____________________________________
_____ Epi-Pen for ______________________________________
_____ Other (please specify) _____________________________
Emergency Contact Information
Name:
_________________________ Address:
__________________________
Telephone #1: ____________________________
Telephone #2: ____________________________
Telephone #3: ____________________________
Name:
_________________________ Address:
__________________________
Telephone #1: ____________________________
Telephone #2: ____________________________
Telephone #3: ____________________________
Name:
_________________________ Address:
__________________________
Telephone #1: ____________________________
Telephone #2: ____________________________
Telephone #3: ____________________________
Parent/Guardian Signature: _____________________________ Date:
_______