Peace Lutheran Confirmation Retreat

PERMISSION SLIP
Student’s Name___________________________________________________ Grade ___________

Dates __1__/__23__/__2011___ through __1__/__24__/_2011__ Transportation _Meet @

Arrowwood
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Cost: $50 per child
Student’s Health Insurance Carrier ___________________ Policy Number ______________________

Birth Date _____/_____/_____ Last Tetanus Injection Date _____/_____/_____

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Current Medications
____________________________________________________________________

Allergies
_____________________________________________________________________________

Special Medical Instructions (please attach separate sheet if necessary)

___________________________________________________________________________________
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An Emergency Call May Be Made To (full name)___________________________________________

Whose Phone Number Is (including area code)_____________________________________________

(Student’s Name)________________________________has the permission of the undersigned to

participate in the CONFIRMATION RETREAT. In the event of an emergency affecting the health or
welfare of this participant, the
sponsors, leaders, or adult chaperones have permission to administer first aid and/or transport the
individual to
the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action
in
response to the emergency will be held blameless. Any medical expenses occurring will be borne by
the parents or
guardians of the participant.
Signature of Parent/ Guardian ____________________________________ Date _____/_____/_____

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Parent/ Guardian’s E-mail__________________________________________

Address_________________________________________________________

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