. . . . . . . . . . . . Trip Date:______ Location__________
Return this half of the form to the leader no later than (date)_______
Notice that daughter will NOT participate in the trip listed
___NO, my daughter ____________________ does NOT have my
permission and will not participate in this trip.
Parent/Guardian signature _____________________Date__________

Permission for participation (please complete and sign where indicated)
___YES! My daughter______________________has my permission
to participate in the trip indicated above.
___YES! My daughter______________________has my permission
to participate in the trip indicated above with the following limitations and/
or reasonable accommodations: (please describe.) Is your daughter taking
medication?__________________________________________________
. . . . . . _________________________________________________
. . . . . . _________________________________________________
. . . . . . _________________________________________________

During the activity, I (we) may be reached at (address)_______________
_________________________________ Phone________________

Mother's day#________________Father's day#__________________
Mother's eve#________________Father's eve#__________________

Family Physician_________________________Phone#______________
If I (we) cannot be reached in the event of an emergency, the following
person is authorized to act in my (our) behalf:
Name:________________________________________________________
Address:_____________________________________________________
Phone #:______________________Relationship:___________________

I will permit photographs of my daughter taken at this event to be used for
Publicity by authorization of the designated members of the council. I do herewith
authorize the treatment by a qualified and licensed medical doctor of my daughter
_____________________________________ in the event of a medical emergency
which, in the opinion of the attending physician, may endanger her life, cause
disfigurement, or physical impairment or undue discomfort if delayed. It is
understood that effort shall be made to contact the undersigned prior to rendering
treatment, but that any of the treatments will not be withheld if the undersigned
cannot be reached.

Parent/Guardian signature___________________________ Date__________

http://www.oocities.org/su611/

---