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Permission Slip

Please fill in appropriate information and,
1) select text below, copy to your word processor, print out, sign, give to leader, or
2)select text below, copy to your word processor, type-in information and e-mail it to a leader. If you are doing this at the last minute, be CERTAIN that the leader knows you are e-mailing the form so that she will check for it on e-mail. A phone call to alert her might be necessary so that your daughter doesn't miss out on an activity...

Permission Slip for THE DUDE RANCH
WEDNESDAY, JUNE 9, 2004



My daughter, ___________________________

has my permission to attend THE DUDE RANCH.





I will drop her off at KRAMER at 12:30 PM on JUNE 9, and will pick her up at 6:30 PM at the Bailer's house, 131 Prevalent Dr.



My daughter is in good physical condition with no serious illness or operation since her last health exam, ____YES ____ NO

If no, please explain _____________________________________________________



Is she currently taking any medications? ____ YES ____ NO

Please list, and include in original container if needed: ____________________

_________________________________________________________________________



Does she have any allergies? ____ Yes ___ No. Please list ________________

________________________________________________________________________



During this time I can be reached at: __________________________________

Phone _____________.

My cell phone number is: __________________________





If I cannot be reached, please contact: (Name) ___________________________ (Address)______________________ Phone ( ) _____________.



My Health Insurance Company is ___________________ Number.__________





In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the person in charge to secure emergency treatment for my child as named above.



Signed __________________________________ Date_________________