LAND BEYOND CHILDCARE PERMISSION SLIP

PARTICIPANT INFORMATION Full name: Age: Grade/School: Street Address: City/State/ZIP: Parent/Guardian name(s (please print : Home phone #:

PARENTAL AUTHORIZATION !ear Parent or "egal Guardian: #our son/daughter/indi$idual under your guardianship is eligi%le to participate in an acti$ity that re&uires transportation a'ay (rom "and )eyond Child Care Center *his acti$ity 'ill ta+e place under the guidance and direction o( parish/school sta(( (rom "and )eyond Childcare DESCRIPTION OF ACTIVITY "ocation: Sun ,alley Fire Station Cost: Free (or children and chaperones !ate o( e$ent: *hursday Septem%er -.th/ -012 *ime o( departure: 3:00am *ime o( return: 1-:00pm 4ode o( transportation to/(rom e$ent: First Student School )us Ser$ice

/%at To 0#i!
1. Sack lunch labeled with name 2. Dress comfortable with sneakers & bring a light jacket or sweater 3. There will be 1 adult teacher or chaperone to ever ! children. "e will have # teachers and chaperones all together with 3$ students present.

Permission Slip 5eturned: 6o "A*75 than Septem%er 18th 'e need to +no' ho' many children 'ill %e present

I( you desire your son/daughter/indi$idual under your guardianship/ to participate in this particular e$ent/ please complete, si ! a!" #et$#! t%e &ollo'i! stateme!t o& co!se!t a!" #elease o& lia(ilit) () Septem%er 18th/ -012 9 date I %e#e() co!se!t to pa#ticipatio! () , m) so!*"a$ %te#*i!"i+i"$al $!"e# m) $a#"ia!s%ip, i! t%e e+e!t "esc#i(e" a(o+e, I &$ll) $!"e#sta!" t%at t%is e+e!t 'ill ta-e place a'a) &#om t%e pa#is% #o$!"s a!" t%at m) c%il" 'ill (e $!"e# t%e s$pe#+isio! o& t%e "esi !ate" sta&& a!"*o# +ol$!tee#s o! t%e state" "ates, I $!"e#sta!" t%at s$c% a! $!"e#ta-i! i!+ol+es a! eleme!t o& #is-, I also i+e co!se!t &o# eme# e!c) me"ical t#eatme!t i& !ecessa#), I "o #e.$est t%at, i& possi(le, I (e co!tacte" p#io# to t#eatme!t, As pa#e!t*le al $a#"ia!, I #emai! &$ll) #espo!si(le &o# a!) le al #espo!si(ilit) '%ic% ma) #es$lt &#om a!) pe#so!al actio!s ta-e! () t%e !ame" pa#ticipa!t, Please si ! i& )o$ %a+e #ea" a!" a #ee" to t%e te#ms a(o+e, I co!se!t &$#t%e# to t%e co!"itio!s state" a(o+e, i!cl$"i! t%e met%o" o& t#a!spo#tatio!,

Parent:s/Guardian:s Signature: *elephone #: !ay:

!ate: 6ight:

Alternate 7mergency Contact: *elephone #: !ay: 6ight:

Allergies or 4edical Concerns: