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Activity Permission Slip
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TO WHOM IT MAY CONCERN:
As a parent and/or guardian, I do herewith authorize
treatment under the direction of any licensed physician of the following
minor in the event of a medical emergency which, in the opinion of the
attending physician, may endanger his or her life, cause disfigurement,
physical impairment, or undue discomfort if delayed. This authority
is granted only after a reasonable effort has been made to reach me by
phone at the number listed below. Name of minor ______________________________ Relationship ______________________ Address ___________________________________ Phone ___________________________ Date or dates when release is intended _________________ Event _____________________ Family Physician _____________________________ Phone __________________________ Specific allergies, chronic illnesses or other conditions ________________________________ ______________________________________________________________________________ Date of last tetanus shot ________________________ Other contact in case of emergency: Name _____________________ Phone ______________ This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. Signed __________________________________ Circle one: Father Mother Legal Guardian |
Please print the permission slip, fill it out
completely and return it to the youth activity leaders.