Empire Academy presents

Mysteries: A Masquerade Prom

April 4, 2009 Prom Permission Slip
I give permission for my child, ______________________, to attend Empire Academy’s 2009 Prom
at the Seascape Golf Club in Aptos. I understand that Prom is from 7:00 pm to 12:00 am, that my
child needs to stay on site at all times, and that there are no ‘in and outs’. This is a formal event, and
your child should be dressed appropriately. As always, Empire Academy events are drug and alcohol
free. If it is suspected that your child is under the influence of any substance, they will be asked to
leave, and you will be called to come pick them up.

Please indicate which dinner choice your child would like:

_____ Chicken Piccata _____ Tri-Tip _____ Pasta with Fresh Vegetables

Please indicate how your child will be leaving:

______ I will pick up my child at ______ a.m. after prom.
______ My child will get a ride home from _____________________ after the prom
______ My child will be going to ________________ with ________________ after the prom
(place) (name)

In case of emergency, I can be contacted at the following numbers during prom:

1st number_________________________ Alternate number:___________________________

If your child wants to bring a guest(s) (Guest(s) must be in high school), please fill out the details
in the box below.

______ My child will be bringing ______ guest(s) to prom. Sinda Merritt,

Director, must receive a call from the guest’s parent or guardian authorizing
attendance.
Name(s) of guest:______________________
Parent Name and phone number:_______________________________
Each guest must provide $60 by March 9th, as well as a signed guest Prom
Permission Slip

In the event of an apparent or real emergency in which medical treatment or hospitalization of my child may be necessary, the undersigned
parent or guardian does hereby authorize and appoint Empire Academy, through its agents, to obtain any medical treatment or hospitalization of
the above named child as they believe necessary and proper for the immediate care and welfare of said child. I do further authorize and direct
any medical doctor or hospital to render any and all treatment believed necessary and proper for the immediate care and welfare of the above
named child and the undersigned agrees to pay for such medical treatment and expenses incurred on behalf of such child and shall hold Empire
Academy and its agents harmless from any and all liability, claims, judgments and costs incurred in or as a result of any such medical treatment
or hospitalization.

Signed:____________________________________ Date:_________________________

Please sign and return this form with $90, which covers dinner, Prom pictures and
casino games by March 9th. Make checks payable to SEA. If you have any
questions, please feel free to call 458-4200.