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Box City Under 18 Permission Slip



City, State, Zip Code_____________________________________________________________

Home Phone____________________________ Cell Phone______________________________

Birth Date______________________________

Parent(s)/Guardian(s) Name_______________________________________________________

Preferred Phone Number In Case of Emergency_______________________________________

Participant Allergy/Medical Concerns_______________________________________________


Name & Phone Number of Another Person to 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. I
understand that if my behavior is deemed disruptive or destructive my parents may be notified
and I may be asked to leave or be sent home.

Participant Signature________________________________________ Date________________

Parent Signature____________________________________________ Date________________

I give permission for my child, ______________________________, to participate in Box City.

I release Box City designated leaders from liability should be my child be injured in any way
during the event. I give permission for Box City leaders to take whatever steps may be necessary
to obtain emergency medical care as warranted.

Parent Signature____________________________________________ Date________________