MAYFIELD HIGH SCHOOL KEY CLUB

PERMISSION SLIP FOR HOSPICE EVENT

FRIDAY, NOVEMBER 12, 2010
Dear parent/guardian,

Please sign this form and give all necessary information in order to authorize the
provision of emergency treatment in case your child becomes ill or is injured while attending
the field trip. Thank you.

I give my child, ______________________________, permission to attend Mayfield High

School’s Key Club Hospice event on Friday, November 12, 2010. This will involve preparing and
serving a meal and cleaning up afterwards. In case of a medical emergency, my child’s physician
is ___________________________, and his/her phone number is
______________________________.

Your Home phone:

Cell phone:

Finally, please list any special instructions (e.g., allergies, special conditions:

Signature of parent/guardian: _______________________________________________