You are on page 1of 2


Gallatin County Public Library 200 West Market St.

Warsaw, Ky. 41095 859-567-2786
I ____________________________ give permission for
child, ________________________________________ to

LEGO Mania

All ages are


Dec. 30th 10:00 a.m. -3:00 p.m.

Light refreshments will be served

Childs Name: ___________________________________________

Please Check

Date of Birth: ___________________________________________



Allergies: ______________________________________________
Medical Conditions:
Parent or Legal Guardian Phone Number:
Alternate Emergency Contact Name and Number:
My child will be:
Has my permission to walk home to this address:
Picked up by:
**If your child is to be picked up, that person HAS to come in and sign the
child out**

Parent/Guardian Signature
Children will NOT be permitted to leave the building prior to the event

*PLEASE NOTE* someone from the Library will contact you prior to this event to
ensure the phone number provided is in good working condition. If we are not able
to make contact with someone on the number provided prior to this event, the child
will NOT be permitted to attend.