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Box City 18+ Permission Slip

Name_____________________________________________________________________ Birth Date_________________________

Address_____________________________________________________________________________________________________

Preferred Phone Number _______________________________________________________________________________________

Participant Allergy/Medical Concerns_____________________________________________________________________________

____________________________________________________________________________________________________________

Name & Phone Number of Emergency Contact:

Name______________________________________ Phone Number______________________

Family Physician_____________________________ Phone Number______________________

Medical Insurance Company__________________________ Policy #_____________________

I understand that the Box City leaders will determine what is appropriate behavior, and I agree I will behave appropriately and act
respectfully toward those with whom I participate. I agree I will not have in my possession or use anything which is or could be
considered a weapon; any type of explosive material; chemicals of any kind including, but not limited to, tobacco, alcohol, or any
other drug, unless they are listed on my medical form as prescribed medication.

Participant Signature______________________________________________________________Date_________________________

Box City 18+ Permission Slip

Name_____________________________________________________________________ Birth Date_________________________

Address_____________________________________________________________________________________________________

Preferred Phone Number _______________________________________________________________________________________

Participant Allergy/Medical Concerns_____________________________________________________________________________

____________________________________________________________________________________________________________

Name & Phone Number of Emergency Contact:

Name______________________________________ Phone Number______________________

Family Physician_____________________________ Phone Number______________________

Medical Insurance Company__________________________ Policy #_____________________

I understand that the Box City leaders will determine what is appropriate behavior, and I agree I will behave appropriately and act
respectfully toward those with whom I participate. I agree I will not have in my possession or use anything which is or could be
considered a weapon; any type of explosive material; chemicals of any kind including, but not limited to, tobacco, alcohol, or any
other drug, unless they are listed on my medical form as prescribed medication.

Participant Signature______________________________________________________________Date_________________________